First Name
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Last Name
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Email
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Phone
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Address
Address 2
City
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Postal code
Date of birth
Weight (Lb.)
Height (Ft./In.)
Are You a U.S. Citizen or Resident?
Yes
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Occupation
Marital Status
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Have You Donated Eggs Before?
Are You Currently Taking Any Medications or Do You Have Any Illnesses or Conditions?
Do You See a Gynecologist Regularly?
Yes
No
Do You Have Regular Menstrual Periods?
Yes
No
Are You Currently Using Birth Control?
Yes
No
Have You Ever Been Pregnant?
Yes
No
Have You Ever Had an Abnormal Pap Smear? (If so, please provide dates and treatment)
Do You Smoke?
Yes
No
Do You Drink Alcoholic Beverages?
Yes
No
Do You Take Any Recreational Drugs?
Yes
No
Have You Ever Been Treated by a Psychologist or a Psychiatrist?
Yes
No
Have You Ever Been Arrested or Convicted of a Crime?
Yes
No
Please Describe Your Ethnic Background
Please Describe Your Education Level
Please Tell Us How You Heard of Our Program, and Why You Are Interested in Being an Egg Donor
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Please Read and Agree to the Following.
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I verify that the information on this application is complete and accurate. I understand that any false statement made by me may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties.
Please Read and Agree to the Following.
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I hereby authorize NAFG to use this information as part of an anonymous profile to submit to prospective recipients and medical professionals for evaluation. This anonymous profile may be presented in written (hard copy) or electronic form to prospective recipients and medical professionals at the discretion of NAFG in its efforts to make an appropriate match. My profile will remain anonymous unless and until I submit prior written consent. I hereby authorize NAFG to use my photograph(s) on its Web site as part of my anonymous profile. This profile will be viewed by registered NAFG users only.
Please Read and Agree to the Following.
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I authorize NAFG to conduct any necessary background checks, including but not limited to criminal, financial, and medical records, pertaining to me. I acknowledge that other interested parties, including but not limited to intended parents, attorneys, medical personnel, etc., will rely on this information. I understand that any false statement made by me may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties. This authorization shall remain valid for two years from the date thereof. A copy shall have the same force as the original.