Utah Fertility Center - Gestational Carrier
1. First Name
 
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2. Last Name
 
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3. Street Address (include apartment number where appropriate)
 
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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 primary phone number you would like us to use to contact you?
 
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8. What is your date of birth?
 
   
9. What is your marital status?
 
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10. How many years have you been together?
 
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11. How many years have you been legally married?
 
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12. Do you have medical insurance?
 
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Please explain "other"
13. What is the name of your health insurance carrier? (enter "n/a" if no insurance)
 
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14. Please provide information regarding your health insurance. (enter "n/a" in the first box if no health insurance)
 
Health Insurance Information
What is the effective date of insurance?:  
Do you have maternity coverage?:  
What is your yearly deductible?:  
What is your co-pay?:  
What is your premium amount?:  
Is this policy through your employer?:  
Which employer?:  
15. How many days per week do you use tobacco in any form?
 
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16. How many days per week does your partner/spouse or roommate smoke per week?
 
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If your partner/spouse or roommate uses tobacco, what form of tobacco is used and are there any courtesy accommodations provided to you?
17. How many days per week do you drink alcoholic beverages?
 
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Please Explain
18. Have you been medically diagnosed or self-diagnosed as an alcoholic or addicted to tobacco?
 
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Please explain "Yes".
19. When is the last time you had marijuana?
 
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20. 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.)?
 
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Please explain which drugs, how often, and any additional information.
21. What is your height?
 
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22. What is your weight?
 
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23. Do you have or have had depression?
 
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If yes, please explain.
24. Do you have or have had diabetes?
 
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If yes, please explain.
25. Do you have or have had eating disorders?
 
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If yes, please explain.
26. Do you have or have had heart problems?
 
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If yes, please explain.
27. Do you have or have had high blood pressure?
 
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If yes, please explain.
28. Do you have or have had migrane headaches?
 
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If yes, please explain.
29. Do you have or have had ovarian cysts?
 
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If yes, please explain.
30. How many times have you been pregnant?
 
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31. Have you ever been hospitalized for psychiatric care?
 
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32. Have you ever been convicted of a crime?
 
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33. Do you currently have any legal cases or claims pending?
 
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34. Do you understand you will need to ultimately submit to us a copy of your obstetric records from your prior pregnancies and deliveries, your most recent physical exam results from your primary care provider, along with a pap smear results and any other tests that were completed?
 
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35. What is your email address for communication with you regarding your pre-screen application?
   
35. Please verify your email address
   
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