Columbia Fertility Associates
Thank you for considering becoming an egg donor with Columbia Fertility Associates. You are only a few questions away from becoming a dream maker.
1. FIRST name
 
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2. LAST name
 
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3. Street address? (include apartment if approprate)
 
---> Street Address Apartment City State Zip
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4. Based on the following address: (address) ... how much time will it take to get to this location? (typical treatment cycle is 11 visits)
 
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5. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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6. Is this phone "text friendly" and may we use it for text, where appropriate?
 
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7. Please select the most accurate response to the decision tree related to your eligibility to work in the USA, your residency, and your citizenship.
 
8. Were you born in the USA?
 
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If no, please provide your birth country.
9. What is your date of birth?
 
   
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. Height
 
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12. Weight
 
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13. What is your highest level of completed education?
 
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14. Is your work schedule flexible?
 
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15. Please answer the following decision tree related to smoking habits (including any form of nicotine products, including e-cigarettes).
 
16. Please select the most accurate answer for the following question about smoking, drinking, marijuana and other drugs (Cocaine, Heroin, etc).
 
Recreational Drugs Smoking Alcohol Marijuana Other Drugs
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17. Please select the most appropriate answers for tattoos, acupuncture and body piercings.
 
Piercing How Many? Most Recent? Sterile Needles? Most Recent Performed by?
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Please provide locations of tattoos and piercings.
18. Please select the most accurate answers regarding question about your experience with the law.
 
Law Times Arrested Times Convicted Misdemeanors Felonies Days of Incarceration Most Recent Incarceration
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Please provide any additional information about convictions.
19. How many times have you donated your eggs?
 
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20. Have you had a baby within the last 12 months?
 
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21. Are your currently breastfeeding?
 
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22. What kind of contraception do you currently use?
 













If "Other", please explain.
23. Have you taken a Depo Provero shot within the past year?
 
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24. Do you have Both Ovaries?
 
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Please Explain "No"
25. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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26. 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.
27. 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.
28. Are you adopted?
 
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29. 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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30. What is your email address for communication with you regarding your pre-screen application?
   
30. Please verify your email address
   
31. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
32. Verify your password