Aspire Fertility - Houston
1. What is your name?
 
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2. What is your street address, city, state and zip code?
 
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3. Please provide us your contact information.
 
Contact Information Number/Email Instructions to FSH regarding contacting you at this number or email
Daytime Phone Number:    
Evening Phone Number:    
Cell Phone Number:    
Work Phone Number:    
Email Address:    
4. What is your date of birth? (age in years, not birthday, is shown to intended parents)
 
   
5. What is your height?
 
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6. What is your weight?
 
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7. What is your body type / bone structure?
 
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8. What is your current form of birth control?
 
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9. What is your natural hair color?
 
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10. What is your race?
 
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11. What is your complexion?
 
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12. Do you currently smoke or have you ever smoked? If yes, please explain when, how many and how often.
 
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Please Explain
13. Do you know your family history including biological parents and grandparents?
 
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14. What is your email address for communication with you regarding your pre-screen application?
   
14. Please verify your email address
   
15. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
16. Verify your password