The New Hope Center for Reproductive Medicine
1. Are you a US citizen or permanent resident?
 
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2. Are you eligible to work in the United States?
 
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3. What is your FIRST name?
 
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4. What is your LAST name?
 
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5. What is your home address?
 
Home Street Address (w/ Apt. #) City State Zip Code
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6. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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7. Who is your cell phone carrier
 
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8. Date of Birth
 
   
9. What is your place of birth? (City, State ... include country if other than US)
 
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10. What is your height?
 
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11. What is your weight?
 
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12. What race would you most likely be affiliated?
 
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If multi-racial, please provide your best description.
13. Are you adopted?
 
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14. What is your highest level of completed education?
 
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15. How many pregnancies have you had?
 
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16. To how many children have you given birth?
 
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17. Do you drink alcoholic beverages?
 
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18. How many cigarettes do you smoke per day?
 
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19. Do you currently smoke cigarettes?
 
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20. How many times have you donated your eggs?
 
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21. Please provide us with times in which you are NOT AVAILABLE.
 
Schedule Sunday Monday Tuesday Wednesday Thursday Friday Saturday
7am - 9am: Yes Yes Yes Yes Yes Yes Yes
9am - 11am: Yes Yes Yes Yes Yes Yes Yes
11am - 1pm: Yes Yes Yes Yes Yes Yes Yes
1pm - 3pm: Yes Yes Yes Yes Yes Yes Yes
3pm - 5pm: Yes Yes Yes Yes Yes Yes Yes
5pm - 7pm: Yes Yes Yes Yes Yes Yes Yes
22. Have you applied or been screened to be an egg donor before?
 
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If yes, provide the name and location of the donor program(s).
23. Are you currently enrolled as an egg donor in another program?
 
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24. Why do you want to become a donor?
 
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25. What resources influenced your decision to apply?
 










If you can be more specific than the above, it would be appreciated.
26. Have you received a piercing and/or tattoo within the past 12 months? If so, please reapply when the 12 months has passed since you received your piercing and/or tattoo.
 
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27. Are you planning on having children within the next two years?
 
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28. Are you planning on living at your current residence or in the Hampton Roads area within the next two years?
 
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29. Does your mother or father have a history of alcoholism or drug abuse?
 
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30. Have you been diagnosed with the Zika virus in the past 6 months
 
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31. Do you live or have you traveled to an area with active transmission of the Zika virus in the past 6 months?
 
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32. Have you had sexual intercourse with a male who has been diagnosed with the Zika virus?
 
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33. Have you had sexual intercourse with a male who has traveled or lived in an area with active ZIKA virus transmission?
 
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34. What is your email address for communication with you regarding your pre-screen application?
   
34. Please verify your email address
   
35. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
36. Verify your password