Thank you for completing the pre-screen application. Once this has been reviewed you will be notified by email regarding your status. If you have any questions please feel free to contact Shawnie Hurt, DEB Coordinator, with MCRM Fertility at shurt@mcrmfertility.com.
1. Legal FIRST Name:
 
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2. Legal LAST Name:
 
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3. Street Address:
 
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4. City:
 
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5. State:
 
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6. Zip Code:
 
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7. What is the least time it takes to get to our office (17300 N. Outer Forty Rd, Suite 101, Chesterfield, MO 63005) from work, school or home?
 
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8. What is your primary phone number?
 
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9. Is it OK to leave a message on your primary phone?
 
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10. Are you a US citizen or permanent resident of the USA?
 
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11. Are you eligible to work in the USA?
 
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12. How did you learn about our egg donation program?
 
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If Friend/Family, please list name of the person who referred you:
13. What race and/or ethnicity best represents you?
 
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If Multi-Racial or Other, please explain:
14. What is your date of birth?
 
   
15. What is your height? (Precise height will be calculated/verified at your first office visit.)
 
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16. What is your current weight in pounds? (Precise weight will be calculated/verified at your first office visit.)
 
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17. Please select your highest level of education COMPLETED.
 
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18. Have you been diagnosed with Chlamydia or Gonorrhea within the last year?
 
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19. Have you ever been hospitalized for psychiatric care?
 
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If yes, please explain:
20. How many nicotine products (cigarettes, e-cigarettes, nicotine gum, etc.) do you use per week? (Nicotine testing will be completed in the office.)
 
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21. Have you ever used marijuana?
 
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22. Have you ever used other recreational drugs such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetamines, Hallucinogens, Tranquilizers (non-medical), PCP, Inhalants, Steroids (non-medical), Ecstacy, or other recreational drugs for NON-MEDICAL purposes?
 
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Please list the name(s) of any/all recreational drug(s) used within the time frame selected above:
23. Have you ever spent time in jail?
 
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If yes, please explain:
24. Do you have both ovaries?
 
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25. Have you previously applied to be a donor with our program?
 
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If yes, please provide additional information.
26. How many total egg donation cycles have you completed in the past?
 
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27. Have you ever donated your eggs or applied to be an egg donor prior to this application?
 
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If yes, please explain:
28. Have you ever had a Depo-Provera shot?
 
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29. How many total pregnancies have you had?
 
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30. Are you currently breastfeeding?
 
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31. Are you adopted?
 
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32. FDA - Have you injected drugs for a non-medical reason in the past 5 years, including intravenous, intramuscular, or subcutaneous injection?
 
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Please Explain
33. FDA - Are you a current or former US military member, civilian military employee, or dependent of a military member or civilian employee, who has resided at US military bases in northern Europe (Germany, Belgium, and Netherlands) for 6 months or more cumulatively from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, or Italy) for 6 months or more cumulatively from 1980 through 1996?
 
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Please Explain
34. FDA - Have you lived cumulatively for 5 years or more in Europe (Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, England, Northern Ireland, Scotland, Wales, Isle of Man, Channel Islands, Gibraltar, Falkland Islands, and Yugoslavia) from 1980 until present?
 
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Please Explain
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.
   

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