Infertility Videos

 
Infertility Clinic Long Island New York

Long Island NY Donor Egg Program

 
Egg Donor Pre Screening
 

Thank you for your interest in becoming an egg donor. The following form will help us determine if you are eligible to be an egg donor. Please note this is a preliminary screener, extensive physical and psychological screenings are also required. Should you have any questions or need immediate assistance, please contact our Donor Egg Coordinator at (516) 562-1763.

FIRST NAME:

AGE:

STREET ADDRESS1:

STREET ADDRESS2:

CITY: STATE: ZIP:

ETHNICITY:

HAVE YOU EVER BEEN PREGNANT: YES NO

   IF YOU HAVE KIDS, HOW MANY?

WERE YOU ADOPTED? YES NO

DO YOU SMOKE: YES NO

DO YOU HAVE OR HAVE YOU EVER HAD ANY MAJOR MEDICAL PROBLEMS: YES NO

IF YOU ANSWERED YES, PLEASE EXPLAIN:

HAVE YOU EVER RECEIVED TREATMENT FOR A PSYCHIATRIC DISORDER: YES NO

IF YOU ANSWERED YES, PLEASE EXPLAIN:

DO YOU HAVE AND TATTOOS OR BODY PIERCINGS: YES NO

   IF YOU ANSWERED YES, WHEN DID YOU ACQUIRE THEM:

HOW DID YOU HEAR ABOUT US:

WHERE DID YOU SEE OUR ADVERTISEMENT:

DAYTIME PHONE:

EVENING PHONE:

E-MAIL:

WHAT IS THE BEST WAY TO CONTACT YOU:

WHAT IS THE BEST TIME OF DAY TO CONTACT YOU:

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