Fertility Specialists of Texas
Thank you for your interest in egg donation. Please fill out the pre-screening application. Once it is reviewed, if you meet the initial eligibility requirements, you will receive an email with a link to complete the entire application. Please allow 3-5 days for a response.
1. Are you currently under a physicians care for any reason?
 
"" 
If yes, please explain.
2. Are you a US citizen or permanent resident?
 
"" 
3. Are you eligible to work in the United States?
 
"" 
4. What is your FIRST name?
 
250 characters remaining "" 
5. What is your LAST name?
 
250 characters remaining "" 
6. How long will it take you to get to our office? (5757 Warren Parkway, Suite 300, Frisco, TX 75034)
 
"" 
7. Have you applied or been screened to be an egg donor before?
 
"" 
If yes, provide the name and location of the donor program(s).
8. Are you currently enrolled as an egg donor in another program?
 
"" 
9. How did you find out about our program?
 
"" 
Please Explain
10. How many times have you donated your eggs?
 
"" 
11. Which ethnicity would you most likely be affiliated?
 
"" 
12. Date of Birth (only your calculated age is shared with Recipients)
 
   
13. What is your height?
 
"" 
14. What is your weight in pounds?
 
"" 
15. What is your highest level of completed education?
 
"" 
16. Is your work schedule flexible?
 
"" 
17. How many cigarettes do you smoke per day?
 
"" 
18. When is the last time you had marijuana?
 
"" 
19. How many drinks do you usually consume in a week?
 
"" 
20. How many immediate family members have alcohol or drug abuse? (Grandparents, parents, self, siblings, or children)
 
"" 
21. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
"" 
22. When was the last time you have had a tattoo or body piercing?
 
"" 
23. If a background check were run on you, would it show any problems with the law (i.e. DUI, custody issues, lawsuits)?
 
"" 
If yes, please explain.
24. Have you ever had any arrests, convictions, sentences, etc.?
 
"" 
If yes, please explain.
25. What is the most number of consecutive days that you have been incarcerated?
 
"" 
26. How many current sexual partners do you have?
 
"" 
27. How many sexual partners have you been with during the past 6 months?
 
"" 
28. How many sexual partners have you been with in your lifetime??
 
"" 
29. What kind of contraception do you use?
 













If "Other", please explain.
30. How many miscarriages have you had?
 
"" 
31. How many ectopic pregnancies have you had?
 
"" 
32. How many abortions have you had?
 
"" 
33. How many stillbirths have you had?
 
"" 
34. How many children have you given birth to?
 
"" 
35. What is the longest length of time it took you or your partner to get pregnant? (in months)
 
"" 
36. Are your currently breastfeeding?
 
"" 
37. Do you have both ovaries?
 
"" 
38. Are your menstrual periods regular (when not on the pill)?
 
"" 
39. Have you ever been told by a medical doctor that you were infertile?
 
"" 
If yes, please explain.
40. Are you adopted?
 
"" 
41. Have you ever had any complications or concerns with anesthesia?
 
"" 
If yes, please explain.
42. Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other medical health professional for any reason?
 
"" 
If yes, when, for how long, for what reason.
43. Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem?
 
"" 
If yes, please list why and date last used.
44. Have you ever taken anti-malarial drugs or had malaria?
 
"" 
45. Have you had a blood transfusion?
 
"" 
46. Have you ever been refused or denied as a blood donor?
 
"" 
If yes, why?
47. What is your email address for communication with you regarding your pre-screen application?
   
48. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
49. Verify your password.