IVF Florida - Cryobank / DEBUSA
1. Today's Date
 
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2. Email Address
 
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3. Full Name
 
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4. Primary Phone
 
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5. Date of Birth
 
   
6. This will require travel. How far are you from the Fort Lauderdale area?
 
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7. What race and/or ethnicity best represents you?
 








8. Are you adopted?
 
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9. What is your height?
 
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10. What is your current weight (in lbs.)? Note: just enter numbers ... example: 107
 
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11. What is the average number of days from the beginning of one menstrual cycle to the start of the next?
 
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12. Are you currently breastfeeding?
 
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13. Do you use nicotine products (i.e. cigarettes, e-cigarettes, nicotine gum, etc.)?
 
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If yes, how many do you use per week?
14. Please explain your motivation for becoming an egg donor.
 
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15. Do you consume alcoholic beverages?
 
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16. Have you ever spent time in jail?
 
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If yes, please explain.
17. Do you have both ovaries?
 
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18. Are you eligible to work in the United States?
 
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19. Are you a US citizen or permanent resident?
 
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20. Is your work schedule flexible?
 
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21. 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).
22. How many times have you donated?
 
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23. Are you currently enrolled as an egg donor in another program?
 
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24. How did you hear about this donor program?
 
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25. What is your email address for communication with you regarding your pre-screen application?
   
25. Please verify your email address
   
26. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
27. Verify your password