1. FIRST name
 
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2. LAST name
 
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3. Street address? (include apartment if approprate)
 
---> Street Address Apartment City State Zip
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4. Within the past 12 months have you, anyone you live with, have close contact with or are intimate with:
 

It is very important that you explain in detail anything referenced above.
5. Mobile Number
 
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6. What is the easiest way to contact you?
 










What are the best times to contact you?
7. State
 
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8. been diagnosed with any form of hepatitis?
 
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9. Country of Residence
 
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If "Other", please provide the name of the country.
10. What Type of Egg Donation are you interested in completing?
 
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Comments:
11. Are you a Prior Egg Donor?
 
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12. Please list all IVF clinics, dates & results (if you have information also list no of eggs retrieved, embryos, pregnancy) of prior donations
 
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13. Are Currently completing an egg donation cycle?
 
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If Yes, Please explain:
14. Please select the best answer related to smoking and tobacco use (including any form of nicotine products, including e-cigarettes, Hookah, Nicotine patch, chewing tobacco)
 
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Please explain for how long you smoked or used tobacco, at what age, how long ago did you quit
15. Do you have both ovaries?
 
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16. Are you adopted?
 
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17. Please provide your Race/Ethnic origin:
 
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If any racial descriptions include "Other", please explain.
18. Please select the most appropriate answers for tattoos, acupuncture and body piercings.
 
Piercing How Many? Most Recent? Sterile Needles? Most Recent Performed by?
--->:        
Please provide locations of tattoos and piercings.
19. What is your date of birth?
 
   
20. 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.
21. Have you traveled to a Zika infested area or been infected with Zika Virus within the past 12 months?
 
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If Yes, Please Explain:
22. What is your eye color?
 
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23. What is your natural hair color?
 
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24. Height
 
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25. Weight
 
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26. Is there anything in your history, the history of someone with whom you have been intimate, or with whom you live with, related to:
 










It is very important that you explain in detail anything referenced above.
27. Do you have hemophilia or other related clotting disorders and have received human-derived clotting factor concentrates in the preceding five years, not including receiving clotting factors once to treat an acute bleeding event more than 12 months ago?
 
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28. Is there anything in your history or the history of someone with whom you have been intimate, who has ever:
 












It is very important to explain in detail any item referenced above.
29. Which of the following have you had?
 










It is very important that you explain in detail anything referenced above.
30. What is your email address for communication with you regarding your pre-screen application?
   
31. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
32. Verify your password.
   

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