1. There are 2 parts of this application process, the Prescreen and the Overall Application. This is our Prescreen Application. Since this is considered tissue donation by the FDA, there are qualification regulations we follow. This Prescreen Application is a little longer than most on the Internet, but you will find out if you qualify or not very quickly. This may be the only opportunity a potential parent has to learn about the family history and health history. Please provide accurate answers and take this very seriously. Please type "I understand" in the box below.
 
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2. 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.
3. Were you born in the USA?
 
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If no, please provide your birth country.
4. FIRST name
 
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5. LAST name
 
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6. Street address? (include apartment if approprate)
 
> Street Address Apartment City State Postal Code Country
>:            
7. To which of our locations are you applying?
 
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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. 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.
11. What is your date of birth?
 
   
12. Height
 
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13. Weight
 
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14. What is your highest level of completed education?
 
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15. Is your work schedule flexible?
 
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16. 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.
17. 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.
18. Which of the following have you had?
 










It is very important that you explain in detail anything referenced above.
19. 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?
20. When is the last time you had marijuana?
 
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21. 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.
22. 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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23. What is the most number of consecutive days that you have been incarcerated?
 
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24. Are your currently breastfeeding?
 
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25. What kind of contraception do you currently use?
 













If "Other", please explain.
26. Have you taken a Depo Provero shot within the past year?
 
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27. Do you have both ovaries?
 
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28. Have you ever been told by a medical doctor that you were infertile and/or conceived with fertility treatments?
 
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If yes, please explain.
29. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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30. Are you adopted?
 
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31. The following questions should only include information regarding the following relatives to: Yourself, Children, Mothers, Fathers, Siblings, Grandparents, Aunts & Uncles (not by marriage), and 1st Cousins.
 
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32. How many relatives has/had the following: BIRTH DEFECTS: Cleft Lip / Palate, Congenital Hip Problems, Club Feet, Heart Defect, Hearing Problems, Spina Bifida, Neural Tube (open spine), Microcephaly, Holoprosencehpaly, Other
 
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33. How many relatives has/had the following: : Down Syndrome, Turner, Fragile X, Klinefelter's, Other.
 
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34. How many relatives has/had the following: : Breast, Colon, Intestinal, Lung, Ovarian, Uterine, Prostate, Testicular, Skin, Stomach, Thyroid, Blood (e.g. leukemia), Other.
 
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35. How many relatives has/had the following: : Stroke, Heart Attack, Congenital Heart Disease, Heart Disease, Heart Defect, Hardening of the Arteries, High Blood Pressure ,High Cholesterol Level, Other.
 
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36. How many relatives has/had the following: REPRODUCTIVE: 2 or more Miscarriages, Stillborn, Premature Menopause, Death of a newborn infant, Childhood death, Birth Defects, Infertility, Premature Birth, Other.
 
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37. How many relatives has/had the following: GENITAL / REPRODUCTIVE: Low Sperm Count, Hermaphroditism, Ambiguous Genitals, Hypospadias, Undescended Testicle(s), Uterine Fibroids, Ovarian Cysts, Ruptured Lumps or Cysts in Breast, Discharge Polycystic, Ovarian Syndrome (PCOS), Pelvic Inflammatory Disease (PID), Endometriosis, Other.
 
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38. How many relatives have/had the following: NEUROLOGICAL: Migraines, Mental Retardation, Senility or Mental Deterioration before age 50, Multiple Sclerosis, Cerebral Palsy, Neurofibromatosis, Epilepsy / Seizures, Attention Deficit Disorder / Hyperactivity, Autism / Asperger's, Alzheimer's Disease, Dementia, Hydrocephalus, Tuberous Sclerosis, Parkinson's Disease, Creutzfeldt-Jakob Disease, Scoliosis, Myasthenia Gravis, Huntington's Disease, Wilson's Disease, Tourette's Syndrome, Other.
 
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39. How many relatives have/had the following: MENTAL HEALTH: Anxiety, Panic Attacks, Anorexia, Bulimia, Other eating disorders, Depression, Schizophrenia, Manic Depressive, Bipolar Disorder, Suicide Attempts, Other.
 
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40. How many relatives have/had the following: ADDICTION: Alcoholism, Drug Abuse, Drug Misuse, Drug Addict, Smoking, Gambling, Compulsive Behaviors, Other.
 
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41. Our organization uses a secure server for some email communication with you. The server is www.donorapplication.com. Email will come to you from no-reply@donorapplication.com. The domain of donorapplication.com needs to be acceptable to your spam filters to ensure email communication. (Google: "how to add an email address to safe list in (Outlook, Google, Yahoo, etc.)"
 
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42. What is your email address for communication with you regarding your pre-screen application?
   
43. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
44. Verify your password.
   

Please add no-reply@donorapplication.com to your email contact list to prevent our response from being flagged as spam.