If you are an out-of-state applicant, please be aware that during your retrieval cycle you will need to do multiple office visits consisting of ultrasounds and lab work along with the retrieval at our clinic in Woodbury, Minnesota. This is usually a 2 week period. There is also an appointment in the screening process that must take place at our clinic as well for FDA compliance. If you are aware and comfortable with these requirements, you may proceed with submitting your application. If you are not comfortable with these requirements, we would not recommend submitting your application and appreciate your time and interest in our program.
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I understand these requirements and wish to proceed at this time
Name
*
First Name
Middle Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Marital status
Married
Single
Domestic partnership
Other
Patient Race
*
American Indian/Alaska Native
Asian
Black/African American
More than one race
Native Hawaiian
Pacific Islander
White
Patient ethnicity
*
Hispanic/Latino
Non-Hispanic
Unreported/Refused to report
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Email contact if you are working through an agency
example@example.com
Patient height and weight
*
Partner name
*
First Name
Middle Name
Last Name
Partner DOB
*
-
Month
-
Day
Year
Date
How did you find out about RMIA?
*
Google
Internet search
Magazine/Newspaper
Blog
Ob/Gyn
Primary MD
Television
Radio
Friend
Current/Previous patient
Drove by building
Insurance
RMIA employee
Other
Are you a current cigarette smoker?
*
No
Yes
Do you consume alcohol, if so, approximately how many per week?
Have you ever been pregnant?
*
No
Yes
If prior pregnancies, please indicate how many and for each pregnancy indicate one of the following options: live birth, stillbirth, miscarriage, elective abortion, ectopic, molar.
How many live birth(s)?
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Delivery
*
Vaginal delivery
C-section
Other
How many miscarriage/abortion(s)?
*
Are you adopted?
No
Yes
What is your current natural hair color?
*
What is your eye color?
*
Hobbies (ie. skating, dancing, traveling, etc.)
Have you donated your eggs before?
NO
Yes
Do you or your partner have any flu-like symptoms (cough, fever, shortness of breath)?
*
No
Yes
Have you been in close contact with someone who has been diagnosed with COVID-19 within the last 14 days?
*
No
Yes
Have you been tested for COVID-19 and awaiting results?
*
No
Yes
Have you been requested to self-quarantine?
*
No
Yes
Have you traveled to an area affected by the Ebola virus in the last 21 days?
*
No
Yes
Have you traveled to an area affected by the Zika virus in the last 8 weeks (6 months for men)?
*
No
Yes
Do you have plans to travel to a Zika affected area in the next 6 months?
*
No
Yes
Upload/take photo of Patient VALID identification (license, passport)
*
Submit
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