IVFMD - Where Miracles Begin
Please take a moment to answer some simple questions, we promise it's not as difficult as a final exam.

Please take a few moments to fill out the Pre-Screening form.  Your application will be reviewed to make sure that the information submitted is within the guidelines of our facility as well as those set by our professional associations and the FDA.  Watch for an e-mail from no-reply@donorapplication.com informing you of the next steps if you have been approved.

 

1. Please select the most accurate response to your eligibility to work in the USA, your residency, and your citizenship.
 
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Please enter your country of birth, any information related to "not" being a permanent resident, and/or non-citizen credentials to be able to legally work.
2. FIRST name
 
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3. LAST name
 
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4. City
 
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5. State
 
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6. Based on the following address: (7501 Las Colinas Boulevard, Suite 200, Irving, TX 75063) ... how much time will it take to get to this location? (typical treatment cycle is 11 visits)
 
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7. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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8. Please select the most accurate response to your experience in donating your eggs.
 
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Please provide any information related to your previous applications and/or donations whether they were with our organization or not.
9. Closest description of your race.
 
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If any racial descriptions include "Other", please explain.
10. What is your date of birth?
 
   
11. Height
 
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12. Weight
 
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13. What is your highest level of completed education?
 
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14. Have you completed egg donation cycles that have resulted in a pregnancy?
 
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15. Is there anything in your history, the history of someone with whom you have been intimate, or with whom you live with, related to:
 










It is very important that you explain in detail anything referenced above.
16. Is there anything in your history or the history of someone with whom you have been intimate, who has ever:
 













It is very important to explain in detail any item referenced above.
17. Which of the following have you had?
 










It is very important that you explain in detail anything referenced above.
18. Please select the best answer related to smoking habits (including any form of nicotine products, including e-cigarettes).
 
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Donating eggs will require no smoking and this will be tested. If you smoke, are you willing to quit?
19. When is the last time you had marijuana?
 
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20. When is the last time you have used other recreational drugs such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetamines, Hallucinogens, Tranquilizers (non-medical), PCP, Inhalants, Steroids (non-medical), Ecstacy, or other recreational drug for NON-MEDICAL purposes?
 
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Please provide the name of the drug.
21. When is the last time you have had a non-medical needle piercing of your body (via acupuncture, tattoo, body piercing, ear piercing, etc.)?
 
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22. What is the most number of consecutive days that you have been incarcerated?
 
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23. Are your currently breastfeeding?
 
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24. What kind of contraception do you currently use?
 













If "Other", please explain.
25. Have you taken a Depo Provera shot within the past year?
 
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26. Do you have both ovaries?
 
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27. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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28. Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other medical health professional for any reason?
 
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If yes, when, for how long, for what reason.
29. 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.
30. Are you adopted?
 
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31. What is your email address for communication with you regarding your pre-screen application?
   
31. Please verify your email address
   
32. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
33. Verify your password
   


Your Pre-screening form will be reviewed soon after it is submitted.  Upon approval, you will be asked to move on to the Donor Application Questionnaire.   Once the Application is reviewed, you will be contacted to set up an appointment for a sonogram with the donor coordinator or one of our physicians.  There will be no charge for that appointment.  We look forward to receiving your information and welcome any questions that you have about the process.