South Jersey Fertility Center
1. FIRST name
 
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2. LAST name
 
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3. Street Address, Apt. #
 
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4. City
 
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5. State (example: NJ, NY, CT ...)
 
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6. Zip Code
 
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7. Based on the following address: (400 Lippincott Drive, Suite 130, Marlton, NJ 08053) ... how much time will it take to get to this location?
 
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8. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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9. 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.
10. 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.
11. Closest description of your race. Note: Combinations of multi-racial descriptions are only in 1 menu. For example, "Black and Latin/Hispanic" is not listed in "Latin/Hispanic and Black" since they are the same.
 
If any racial descriptions include "Other", please explain.
12. What is your date of birth?
 
   
13. Height
 
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14. Weight
 
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15. How did you hear about us? Website/Google/Personal Referral
 
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16. What is your highest level of completed education?
 
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17. Is your work schedule flexible?
 
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18. Have any of your jobs (or other activities) required prolonged exposure to chemicals?
 
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Please explain:
19. 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.
20. 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.
21. Which of the following have you had?
 










It is very important that you explain in detail anything referenced above.
22. 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?
23. When is the last time you had marijuana?
 
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24. 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.
25. Have you ever used IV (intravenous) Drugs?
 
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26. What is the most number of consecutive days that you have been incarcerated?
 
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27. Are your currently breastfeeding?
 
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28. Have you taken a Depo Provero shot within the past year?
 
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29. Do you have both ovaries?
 
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30. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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31. 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.
32. 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.
33. Were you born in the USA?
 
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If no, please provide your birth country.
34. Are you adopted?
 
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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