Utah Fertility Center - Egg Donation
Thank you for beginning this process of becoming an egg donor! This is the pre-screening portion to the donor application. Once you complete it, the application will be reviewed by our third party team. Watch your email 2-5 days after you finish this portion for a confirmation on whether or not you have qualified to proceed to the entire donor application.
1. Legal FIRST Name:
 
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2. Legal LAST Name:
 
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3. What is your primary phone number?
 
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4. Which location is closest to you?
 
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Please explain "Other":
5. Are you a US citizen or permanent resident of the USA?
 
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6. Are you eligible to work in the USA?
 
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7. What race and/or ethnicity best represents you?
 
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If Multi-Racial or Other, please explain:
8. 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.
9. What is your date of birth?
 
   
10. What is your height? (Precise height will be calculated/verified at your first office visit.)
 
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11. What is your current weight in pounds? (Precise weight will be calculated/verified at your first office visit.)
 
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12. Will you be available to complete the egg donation within the next 4-6 months?
 
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13. Please describe the flexibility in your current day to day schedule.
 
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14. Please select your highest level of education completed.
 
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15. Have you been diagnosed with Chlamydia or Gonorrhea within the last year?
 
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16. Have you ever been hospitalized for psychiatric care?
 
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If yes, please explain:
17. How many nicotine products (cigarettes, e-cigarettes, nicotine gum, etc.) do you use per week? (Nicotine testing will be completed in the office.)
 
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18. Have you ever used marijuana?
 
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19. Have you ever used other recreational drugs such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetamines, Hallucinogens, Tranquilizers (non-medical), PCP, Inhalants, Steroids (non-medical), Ecstacy, or other recreational drugs for NON-MEDICAL purposes?
 
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Please list the name(s) of any/all recreational drug(s) used within the time frame selected above:
20. How many alcoholic drinks do you usually consume in a week?
 
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21. Have you ever been convicted of a crime?
 
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If yes, for what reason?
22. Have you ever spent time in jail?
 
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If yes, please explain:
23. What is your marital status?
 
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24. Do you have both ovaries?
 
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25. Have you previously applied to be a donor with our program?
 
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If yes, please provide additional information.
26. How many total egg donation cycles have you completed in the past?
 
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27. Have you ever received any type of fertility treatment?
 
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If yes, when and on what basis?
28. Have you ever had any procedures concerning your ovaries, uterus, or cervix?
 
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If yes, please explain:
29. What method of birth control are you CURRENTLY using?
 
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30. When is the last time you have had a Depo-Provera shot?
 
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31. Have you ever used the Mirena IUD?
 
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32. At what age did your menstrual periods begin?
 
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33. Are your menstrual periods regular (24-36 days)?
 
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34. What is the average number of days from the beginning of one menstrual cycle to the start of the next menstrual cycle?
 
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35. Are you currently breastfeeding?
 
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36. Are you adopted?
 
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37. Are there known genetic diseases or conditions that run in your family? (i.e. Cystic Fibrosis, Spinal Muscular Atrophy, Sickle Cell Anemia, Tay Sachs, etc.)
 
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If yes, please explain:
38. Are there any members of your family, including yourself and children, with a history of learning/intellectual disabilities? (i.e. ADD, ADHD, Autism, Dyslexia, etc.)
 
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If yes, please explain.
39. What is your email address for communication with you regarding your pre-screen application?
   
39. Please verify your email address
   
40. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
41. Verify your password