1.

First Name *

2.

Last Name *

3.

What is your home address? *

  Street Address City State Zip Code
:

4.

Distance from Austin, Texas *

5.

Primary Phone (include area code) *

6.

Secondary Phone (include area code)

7.

Date of birth *

8.

Height *

9.

Weight *

10.

Race *

11.

What is the highest level of education you have completed? *

12.

Are you adopted? *

13.

Are you pregnant or breastfeeding? *

14.

Have you ever been told you are infertile by a doctor? *

15.

Have you been vaccinated in the past 6 months? *

16.

Do you have any history of any significant emotional or psychological problems? *

17.

Are you currently under a physician's care for any reason? *

18.

List all medications that you have taken in the proceeding 12 months (prescription). Enter "N/A" in the first box if you have not taken medications.

  Medication How Often Reason
1
2
3
4
5
6
7

19.

List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.). Enter "N/A" in the first box if you have not taken any OTC medications.

  Medication How Often Reason
1
2
3
4
5
6
7

20.

Are there any known genetic diseases or conditions that run in your family? *

21.

Please explain any personal or family related medical conditions that you are aware of?

22.

Do you have medical insurance? *

23.

Within the preceding 12 months, have you undergone tattooing, ear piercing, or body piercing in which sterile procedures were not used e.g., contaminated instruments and/or ink were used, or shared instruments that had not been sterilized between procedures were used? *

24.

When is the last time you used other recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)? *

25.

When is the last time you had marijuana? *

26.

Have you ever been convicted of a felony? *

27.

Are you eligible to work in the United States? *

28.

Are you a US Citizen or permanent resident? *

29.

Have you applied or been screened to be an egg donor before? *

30.

Previous Donor *

31.

How many times have you donated your eggs? *

32.

Are you currently enrolled as an egg donor in another program? *

33.

How did you hear about TFC's egg donor program? *


What is your email address for communication with you regarding your pre-screen application?
(6-20 characters with 4 or more letters and 1 or more numbers)
(Must match)