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1. |
What is your FIRST name? |
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2. |
What is your LAST name? |
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3. |
What is your mailing address? |
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4. |
What is the primary phone number (include area code) to use for contact and leaving messags? |
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5. |
What is your date of birth? |
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6. |
What is your height? |
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7. |
What is your weight? |
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8. |
What is your eye color? |
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9. |
What is your natural hair color? |
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10. |
What race would you most likely be affiliated? |
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Description of "other" ...
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11. |
Are you adopted? |
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12. |
Is your work schedule flexible? |
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Please provide times when you definately are not available.
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13. |
How many times have you donated? |
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14. |
Are you currently enrolled as an egg donor in another program? |
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15. |
Have you had a blood transfusion? |
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16. |
Have you ever been refused or denied as a blood donor? |
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17. |
Do you currently smoke cigarettes? |
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18. |
Have you ever used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)? |
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19. |
Have you had acupuncture, ear and/or body piercing or tattooing in which sterile procedures MAY NOT HAVE been used? |
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20. |
Are your currently breastfeeding? |
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21. |
What is/are your reasons for wanting to donate eggs? |
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250 characters remaining
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22. |
What resources have influenced your decision to apply? |
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Please provide which website, radio station, newspaper or magazine.
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