US Residency Status -- Select an option --US CitizenPermanent ResidentNeither

To apply for our program you must agree with the following statements

I agree to answer each of the following questions truthfully.
I understand I must be a non-smoker and non-drug user.
I understand I will be required to attend approximately 10-12 appointments and will have a number of blood draws and vaginal ultrasounds.
I understand I must take self-administered injections for approximately 21 days.
I understand I will undergo egg retrieval under light IV sedation.
I understand the medical and psychological risks associated with egg donation.
I understand the process is an extremely serious matter and the recipient is depending on my trust, honesty, maturity and commitment to comply with all instructions.
I understand that I must have both ovaries to participate.
I understand that I cannot use Depo, Mirena IUD or Implants as a current form of birth control.
I understand that if I am adopted, I must know my biological mother and biological father’s health history, as well as be able to answer all questions marked with a red asterisks in the Family History section.
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How often do you use the following?
Please note do not include any over-the-counter medications in the answers below.

Amphetamines -- Select an option --NeverSeldomOccasionallyOftenVery Often
Anti-depressants -- Select an option --NeverSeldomOccasionallyOftenVery Often
Barbiturates -- Select an option --NeverSeldomOccasionallyOftenVery Often
Beer -- Select an option --NeverSeldomOccasionallyOftenVery Often
Cigarettes -- Select an option --NeverSeldomOccasionallyOftenVery Often
Cocaine -- Select an option --NeverSeldomOccasionallyOftenVery Often
Coffee -- Select an option --NeverSeldomOccasionallyOftenVery Often
Heroin -- Select an option --NeverSeldomOccasionallyOftenVery Often
Inhalants -- Select an option --NeverSeldomOccasionallyOftenVery Often
Liquor -- Select an option --NeverSeldomOccasionallyOftenVery Often
Marijuana -- Select an option --NeverSeldomOccasionallyOftenVery Often
PCP -- Select an option --NeverSeldomOccasionallyOftenVery Often
Tranquilizers -- Select an option --NeverSeldomOccasionallyOftenVery Often
Wine -- Select an option --NeverSeldomOccasionallyOftenVery Often
If you indicated any of the above, please explain in as much detail as possible:
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Referrer's Name (Optional)
Comments / Notes (Optional)
Please check this box to confirm that the information provided is true and accurate.

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