Aspire Fertility - San Antonio
 




1. Are you a US citizen or permanent resident?
 
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2. Are you eligible to work in the United States?
 
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3. What is your FIRST name?
 
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4. What is your LAST name?
 
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5. What is your street address?
 
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6. What is your city?
 
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7. What is your state?
 
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8. What is your zip code?
 
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9. What is your home phone number?
 
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10. Is it OK to leave a message on your home phone?
 
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11. Is this phone number able to receive text messages that can be used to communicate with you? Also, will you be the only person reading your text messages?
 
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12. What is the shortest amount of time it will it take to get to either our Austin or San Antonio locations? (typical treatment cycle is 8 visits)
 
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13. Have you applied or been screened to be an egg donor before?
 
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If yes, provide the name and location of the donor program(s).
14. Are you currently enrolled as an egg donor in another program?
 
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15. How many times have you donated your eggs?
 
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16. If you are adopted, do you know your biological information?
 
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Feel free to provide additional information if desired.
17. What race would you most likely be affiliated?
 
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18. What is your date of birth?
 
   
19. What is your height?
 
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20. What is your weight?
 
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21. Please select your highest level of education achieved.
 
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If a Trade School, what trade? If a Degree, what major?
22. Is your work schedule flexible?
 
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23. How many cigarettes do you smoke per day?
 
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24. When is the last time you had marijuana?
 
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25. How many days per week do you drink alcohol?
 
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26. If you drink almost every day, how many drinks do you have each day?
 
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27. If a background check were run on you, would it show any significant problems with the law (i.e. theft, fraud, violence, possession of drugs, DUI, custody issues, lawsuits)?
 
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If yes, please explain.
28. Have you ever spent time in jail?
 
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29. Do you have both ovaries?
 
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30. Are your menstrual periods regular (when not on the pill)?
 
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31. Have you taken a Depo Provera shot within the past year?
 
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32. 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.
33. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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34. Are you currently under a physicians care for any reason?
 
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If yes, you MUST provide an explanation. This does not automatically disqualify you to become an egg donor.
35. Have you ever had any complications or concerns with anesthesia?
 
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If yes, please explain.
36. Is there anything in your history, the history of someone with whom you have been intimate, or with whom you live with, related to:
 










37. 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.
38. Which of the following have you had?
 










It is very important that you explain in detail anything referenced above.
39. Have you had a medical diagnosis of Zika Virus in the past 6 months?
 
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40. Have your traveled or resided in any of the following Countries: Cape Verde, Caribbean, Martinique, St Maartan, Trinidad and Tobago, U.S. Virgin Islands, Central America, Mexico, Pacific Islands or South America in the last 6 months?
 
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If yes, you MUST provide your travel dates.
41. Have you had sex with a person known to have been diagnosed with the Zika virus, or known to have traveled to the above Countries within the past 6 months?
 
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42. How did you hear about our program?
 
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Please provide the referral name so we can thank them.
43. 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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44. What is your email address for communication with you regarding your pre-screen application?
   
44. Please verify your email address
   
45. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
46. Verify your password