1. FIRST name
 
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2. LAST name
 
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3. What is your date of birth?
 
   
4. Are you adopted?
 
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5. Are you a US citizen or permanent resident?
 
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6. Are you eligible to work in the United States?
 
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7. Height
 
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8. Weight
 
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9. Closest description of your race
 
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If multi-racial, please provide your closest description.
10. Are you on birth control? If yes, Please list type (I.e: IUD (which type), Birth control pills, Depo Provera)
 
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11. What is your highest level of completed education?
 
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12. By selecting "Agree", you are stating that you have answered all questions to the best of your ability, without purposeful omission or deception. You understand that egg donation is considered "tissue donation" according to the FDA. This is a process that requires maturity, as it is a serious issue related to all parties involved.
 
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13. 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.
14. Do you have both ovaries?
 
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15. Are your menstrual periods regular (when not on the pill)?
 
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16. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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17. Have you ever had any complications or concerns with anesthesia?
 
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If yes, please explain.
18. 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.
19. 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.
20. Have you spent 3 months or more, cumulatively, in the UK (England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands) from the beginning of 1980 through the end of 1996?
 
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21. Have you lived cumulatively for 5 years or more in Europe (Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, England, Northern Ireland, Scotland, Wales, Isle of Man, Channel Islands, Gibraltar, Falkland Islands, and Yugoslavia) from 1980 until present?
 
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22. How many cigarettes do you smoke per day?
 
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23. Have you ever used recreational or illegal drugs (cocaine, marijuana, LSD, heroin, barbituates, narcotics, opiates, amphetamines, hallucinogens, traquilizers, PCP, steroids, or etc)? If yes, which one(s) and when did you last use them?
 
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24. Have you ever had any problems with the law (examples: DWI, DUI, custody issues, lawsuits?) If yes, please explain
 
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25. 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).
26. Are you currently enrolled as an egg donor in another program?
 
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27. How many times have you donated your eggs?
 
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28. Is your work schedule flexible?
 
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29. What is your preferred method of communicating routine information?
 
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30. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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31. 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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32. What is your email address for communication with you regarding your pre-screen application?
   
33. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
34. Verify your password.
   

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