Coastal Fertility Specialists (DEB USA)
Thank you for your interest in Coastal Fertility Specialists Donor Egg Program. Please, allow several business days for us to review your initial application. Once reviewed if you meet the criteria necessary for donation we will contact you regarding your next steps. Please, feel free to contact us if you have any questions.
phone: 843-883-5800
email: chyrl.benjamin@coastalfertility.us
1. Legal LAST Name:
 
250 characters remaining "" 
2. Legal FIRST Name:
 
250 characters remaining "" 
3. What is your primary phone number?
 
250 characters remaining "" 
4. What is your secondary phone number?
 
250 characters remaining "" 
5. Are you eligible to work in the USA?
 
"" 
6. FDA - Are you a current or former US military member, civilian military employee, or dependent of a military member or civilian employee, who has resided at US military bases in northern Europe (Germany, Belgium, and Netherlands) for 6 months or more cumulatively from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, or Italy) for 6 months or more cumulatively from 1980 through 1996?
 
"" 
Please Explain
7. FDA - 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?
 
"" 
Please Explain
8. Please select your highest level of education COMPLETED.
 
"" 
9. What is your date of birth?
 
   
10. What is your height? (Precise height will be calculated/verified at your first office visit.)
 
"" 
11. What is your current weight in pounds? (Precise weight will be calculated/verified at your first office visit.)
 
"" 
12. Are you adopted?
 
"" 
13. How many nicotine products (cigarettes, e-cigarettes, nicotine gum, etc.) do you use per week? (Nicotine testing will be completed in the office.)
 
"" 
14. What method of birth control (pregnancy prevention) are you CURRENTLY using?
 
"" 
15. Have you been diagnosed with Chlamydia or Gonorrhea within the last year?
 
"" 
16. How did you learn about our egg donation program?
 
"" 
If Friend/Family, please list name of the person who referred you:
17. What is your email address for communication with you regarding your pre-screen application?
   
17. Please verify your email address
   
18. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
19. Verify your password