IVF Florida
1. What is your FIRST name?
 
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2. What is your LAST name?
 
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3. This will require travel. How far are you from the Fort lauderdale area?
 
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4. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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5. Are you eligible to work in the United States?
 
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6. Are you a US citizen or permanent resident?
 
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7. What is your date of birth?
 
   
8. What race would you most likely be affiliated?
 
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Please Explain
9. Are you adopted?
 
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10. What is your height?
 
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11. What is your weight?
 
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12. Is your work schedule flexible?
 
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Please provide times when you definately are not available.
13. Do you have both ovaries?
 
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14. Are your periods regular when you are not on any type of hormonal birth control such as the pill, etc.?
 
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15. Are your currently breastfeeding?
 
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If yes, when will you stop?
16. Have you ever been told you were infertile?
 
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If yes, when and why?
17. Do you currently smoke cigarettes?
 
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18. How many cigarettes do you smoke per day?
 
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19. When is the last time you had marijuana?
 
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20. How many drinks do you usually consume in a week?
 
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21. Have you ever used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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If yes, which one(s) and when did you last use them?
22. Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem?
 
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If yes, please list why and date last used.ease Explain
23. Have you ever taken anti-malarial drugs or had malaria?
 
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Please Explain
24. Have you had acupuncture, ear and/or body piercings or tattooing on your body?
 
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If yes, please provide details.
25. Have you had a blood transfusion?
 
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If yes, when?
26. Have you ever been refused or denied as a blood donor?
 
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If yes, why?
27. Have you spent 3 months or more cumulative in the United Kingdom from 1980 through 1996?
 
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Please Explain
28. From 1980 through 1990, were you a member of the US military, a civilian military employee or a dependent of a member of the US military, residing in US military bases in Northern Europe (Germany, Belgium and the Netherlands) for 6 months or more, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, Italy) for 6 months or more from 1980 through 1996?
 
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Please Explain
29. Have you spent 5 or more years cumulative in Europe?
 
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Please Explain
30. Have you applied or been screened to be an egg donor before?
 
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If yes, provide the name and location of the donor program(s).
31. Are you currently enrolled as an egg donor in another program?
 
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32. How many times have you donated?
 
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33. What is/are your reasons for wanting to donate eggs?
 
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34. What resources have influenced your decision to apply?
 







Please provide which website, radio station, newspaper or person who referred you.
35. What is your email address for communication with you regarding your pre-screen application?
   
36. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
37. Verify your password.