Fertility Center of New Mexico
1. I understand there are two parts to this process, the pre-screen application and the overall application. This is the pre-screen application. Based on this application, you will be notified via email from no-reply@donorapplication.com whether you were accepted to advance to complete the overall application or not. If you are not accepted, it does not mean you are unhealthy or should expect reproductive issues in the future. This is considered tissue donation in the eyes of the FDA and has many guidelines for qualification.
 
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2. Are you eligible to work in the United States?
 
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3. Are you a US citizen or permanent resident?
 
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4. FIRST name
 
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5. Is your work schedule flexible?
 
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6. LAST name
 
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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. 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).
9. Are you currently enrolled as an egg donor in another program?
 
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10. How many times have you donated your eggs?
 
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11. Closest description of your race
 
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If multi-racial, please provide your closest description.
12. What is your date of birth?
 
   
13. Height
 
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14. Weight
 
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15. What is your highest level of completed education?
 
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16. How many cigarettes do you smoke per day?
 
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17. What is the most number of consecutive days that you have been incarcerated?
 
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18. What kind of contraception do you use?
 













If "Other", please explain.
19. Have you taken a Depo Provero shot within the past year?
 
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20. Are your currently breastfeeding?
 
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21. Do you have both ovaries?
 
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22. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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23. 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.
24. 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.
25. Are you adopted?
 
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26. 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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27. What is your email address for communication with you regarding your pre-screen application?
   
27. Please verify your email address
   
28. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
29. Verify your password