Fertility Specialists Medical Group
1. Are you eligible to work in the United States?
 
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2. Are you a US citizen or permanent resident?
 
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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. Do you have both ovaries?
 
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6. What is your date of birth?
 
   
7. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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8. What is your mailing address?
 
Address Street Address Apartment City State Zip Code
Mailing Address:          
9. What is your height?
 
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10. What is your weight?
 
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11. What is your eye color?
 
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12. What is your natural hair color?
 
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13. What race would you most likely be affiliated?
 
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Please Explain
14. Which best describes your level of education?
 
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Degree Earned/ Major:
15. Are you currently under a physicians care for any reason (other than routine checkups)?
 
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If yes, please explain.
16. List all medications that you have taken in the proceeding 12 months (prescription).
 
Medications Medication How Often Reason
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17. List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.).
 
OTC Medications Medication How Often Reason
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18. How many pregnancies have you had? If 0, please skip questions 4-9)
 
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19. Have you had acupuncture, ear and/or body piercings or tattooing on your body?
 
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If yes, please provide details.
20. Please list and describe all of your tattooing and body piercings. (Enter "N/A" if you do not have any tattoos or body piercings).
 
Tattoo's/Piercings Date Received Description Location on Body Sterile Needles Used?
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21. Do you currently smoke cigarettes?
 
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22. How many cigarettes do you smoke per day?
 
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23. What best describes your alcohol consumption?
 
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24. How many drinks do you usually consume in a week?
 
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25. Have you ever used recreational or illicit drugs (marijuana, cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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If yes, which one(s) and when did you last use them?
26. When was the last time you used recreational drugs?
 
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27. How many times have you donated eggs?
 
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28. How did you hear about us?
 








Please provide which website, radio station, or person who referred you.
29. If you were referred by a friend, what is their name?
 
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30. 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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31. What is your email address for communication with you regarding your pre-screen application?
   
31. Please verify your email address
   
32. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
33. Verify your password