Surrogacy Options of America - Egg Donation
 

1. Welcome the the pre-screen application. Did you find us through FertilityNetwork.com?
 
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2. Please select the most accurate response to the decision tree related to your eligibility to work in the USA, your residency, and your citizenship.
 
3. FIRST name
 
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4. LAST name
 
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5. Street address? (include apartment if appropriate)
 
--> Street Address Apartment City State Zip
--->:          
6. There are laws for each state that we must follow for this process. In what state is your primary residence?
 
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7. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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8. Are you willing to travel to complete an egg donation cycle?
 
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9. Please select the most accurate response to the decision tree about your experience in donating your eggs.
 
10. 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.
11. What is your date of birth?
 
   
12. Height
 
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13. Weight
 
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14. What is your highest level of completed education?
 
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15. Is your work schedule flexible?
 
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16. Are your currently breastfeeding?
 
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17. What kind of contraception do you currently use?
 













If "Other", please explain.
18. Have you taken a Depo Provero shot within the past year?
 
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19. Do you have both ovaries?
 
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20. 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.
21. Are you adopted?
 
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22. 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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23. Lastly, can you help us understand our marketing efforts? How did you hear about us?
 
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Please Explain
24. What is your email address for communication with you regarding your pre-screen application?
   
25. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
26. Verify your password.