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Name
First Name
Last Name
Email
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Confirmation Email
example@example.com
Phone Number (used to contact you with egg donor matches)
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Area Code
Phone Number
State or Providence of Residence (used to match you as an Egg Donor)
*
Birth Date
*
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Month
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Day
Year
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Age
Please Enter Height and Weight
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Prior Egg Donor?
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New Donor
Experienced Donor
Are you adopted?
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No
Yes, but I know my family's medical history
Yes, I do not know my family's medical history
Race/Ethnicity (select ALL that apply).
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Arabic
Armenian
Asian
Pacific Islander
African American
African (Black)
African (White)
Caribbean/Islander
Caucasian/White
Eastern European
East Indian
Egyptian
Greek
Hispanic (Black)
Hispanic (White)
Jewish
Italian/Sicilian
Mediterranean
Native American
Native Taino
South American
South Asian
Other
Race/Ethnicity
*
Select
Armenian
Asian
Pacific Islander
African American
African (Black)
African (White)
Caribbean/Islander
Caucasian/White
Eastern European
East Indian
Egyptian
Greek
Hispanic (Black)
Hispanic (White)
Jewish
Italian/Sicilian
Mediterranean
Native American
Native Taino
South American
South Asian
Do you have 2 healthy ovaries and a menstrual cycle (period) every month?
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Yes
No
When not on birth control, do you have a menstrual cycle (period) every 25-35 days?
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Yes
No
Have you ever been diagnosed with PCOS, Endometriosis, Fibroids or Infertility?
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Yes
No
Are you aware of any genetic or hereditary conditions such as heart disease, cancer, alcoholism, physical deformities, neurological conditions in your family
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Yes
No
Have you ever been diagnosed with Diabetes, High Blood Pressure or Sepsis?
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Yes
No
Not sure
Has any of your relatives had Creutzfeldt-Jakob disease?
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Yes
No
Have you ever been diagnosed with severe anxiety or depression?
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Yes
No
Have you ever had sexual contact with anyone who was born or lived in Africa, or received a dura mater (or brain covering) graft?
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Yes
No
Have you tested positive or are you a carrier for any of these conditions (select ALL that apply):
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Not Applicable
Down syndrome
FragileX syndrome
Klinefelter syndrome
Triple-X syndrome
Turner syndrome
Thalassemia
Tay-Sachs disease
Sickle Cell Anemia
Huntington's Disease
Choroideremia or LCA
Other
Have you had any of the following conditions (select ALL that apply):
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Breast Cancer
Ovarian Cancer
Leukemia
Any type of Cancer
Heart problems
Lung problems
Blood Disease
Bleeding Condition
Other
Have you ever smoked cigarettes, hookah, e-cigs, Juul, worn a nicotine patch or chewed tobacco?
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No, I have never used any form of tobacco or Juuled
Yes, for less than 6 months and then I quit
Yes, for less than 1 year and then I quit
Yes, I have every day for the past 6 months
Yes, I have every day for the past year
Yes, I have every day for more than a year
Other
Do either you or your parents drink more than 2 glasses of alcohol on a daily basis?
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Yes
No
Have you ever been convicted of a misdemeanor or felony in the last 5 years? (Example DUI, DWI, Theft, Possession, etc.)
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Yes
No
Have you ever been in juvenile detention, lockup, jail, or prison for more than 72 hours?
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Yes
No
Have you ever used any of these prescription or recreational drugs in any form? Please select the names of the medication used. Select "Not Applicable" if you have not used any of these medications.
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Not Applicable
Heroine
Adderall
Valium (Diazepam)
Ambien (Zolpidem)
Methadone
Cocaine
Morphine
Ecstasy
Molly (MDMA)
Methamphetamine
Soma (Carisoprodol)
Ketamine
Oxymorphone
Buprenorphine
Ativan (Lorazepam)
LSD
DMT
Ritalin
Xanax (Alprazolam)
Vicodin (Hydrocodone)
OxyContin (Oxycodone)
Clonazepam (Klonopin)
Other
Have you EVER taken any of these medications: Propecia© (finasteride) Accutane© (Amnesteem, Claravis, Sotret, isotretinoin) Soriatane© (acitretin) Tegison© (etretinate) Growth Hormone Insulin Hepatitis B Immune Globulin Unlicensed Vaccine usually associated with a research protocol?
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Yes
No
Between 1980 and 1996, did you live in the following Western European countries (France, Germany, Austria, Austria, Spain, Bavaria, Belgium, Italy, Portugal) or Great Britain (the Channel Islands, England, Falkland Islands, Gibraltar, Isle of Man, Northern Ireland, Scotland, Wales) for more than 3 months?
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Yes
No
In the past 12 months, have you had any of the following procedures: (i). Blood transfusion; (ii). Organ, tissue, or bone marrow transplant; (iii). Skin or bone graft; (iv). Contact with someone else’s blood; (v). Accidental needle-stick?
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Yes
No
In the past 12 months, have you been diagnosed with or had sexual contact with anyone that has had any of the following (please select ALL that apply):
*
Not Applicable
Has tested positive or has been treated for Hepatitis B or C
Has or tested positive for the HIV/AIDS virus
Tested positive for Chlamydia, Trichomoniasis, or Genital Crabs within the past 6 months
Tested positive for Gonorrhea within the past 6 months
Ever tested positive for Syphilis
Had sexual contact with a male who has ever had sexual contact with another male
Takes drugs, money or other payment for sex
Hemophilia or has used clotting factor concentrates
Ever used needles to take drugs or steroids, or anything not prescribed by their doctor
Had Chagas’ disease or Babesiosis
How did you hear about our egg donation agency?
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