Donor Pre-Screening Questions | Reproductive Assistance

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First Name

Last Name

Retype email:

Phone

Is this a mobile phone number?

Yes

Preferred Method of Contact

Phone

Text

May we text you at the number you provided?

Yes

Best Time to Reach You

Morning

Afternoon

Evening

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Today Clear

What is your height?

What is your current weight (lbs)?

lbs

Address Street Address line 1:

Address Street Address line 2:

City:

State:

Zip Code:

Are you a US citizen or permanent resident?

Yes

Are you eligible to work in the US?

Yes

How did you hear about us?

If Personal Referral, please share their name.

If Fertility Group, please share what group.

If Other, please specify.

Are you willing to give yourself injections as part of the medication protocol for up to four weeks for donation?

Yes

What resources have influenced you decision to apply?

Egg donors are usually monitored at fertility offices from 7am - 12 noon local time. Do you have the flexibility to attend appointments at this time for approximately two weeks while on medication?

Yes

Do you have the ability and flexibility with your schedule to travel for up to ten days to cycle in a different city?

Yes

Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem?

Yes

Do you have any children?

Yes

If yes, how many children?

Have you donated eggs before?

Yes

How many times have you donated?

In the past 12 months, have you had sex with a man who has had sex with another man in the past 5 years?

Yes

Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular, or subcutaneous reproduction?

Yes

Do you have a clotting disorder for which you have received human-derived clotting factor concentration?

Yes

Have you had sex for drugs for money in the past 5 years?

Yes

Have you had sex in the past 12 months with anyone who would have answered "yes" to the above 4 questions?

Yes

In the past 12 months, have you had sex with a person known or suspected to have HIV, or active hepatitis B or C?

Yes

In the past 12 months, have you been in jail for more than 3 days in a row?

Yes

In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B, and/or hepatitis C infected blood through percutaneous inoculation, contact with an open wound, non-intact skin, or mucous membrane?

Yes

In the past 12 months, have you been in close contact (i.e. sharing kitchen and bathroom) with a person having active viral hepatitis?

Yes

Are you adopted?

Yes

Do you know your family genetic history?

Yes

Are there any genetic diseases that run in your family?

Yes

Please explain familial genetic diseases:

Do you currently smoke cigarettes?

Never

Rarely

Occationally

Daily

Do you drink alcoholic beverages?

Never

Less than 5 drinks a year

Less than 5 drinks a month

Less than 5 drinks per week

5 or more drinks per week

Frequently

Upon clicking the Submit button, assuming the pre-screening criteria is met, you will be taken to the User Portal to continue your application in our secure portal. An email will be sent to you with information on how to log in to the User Portal in the future. Be sure to check your Junk/Spam folder for this information.