1.

FIRST name *

2.

LAST name *

3.

City *

4.

State *

5.

Based on the following address: (address) ... how much time will it take to get to this location? (typical treatment cycle is 11 visits) *

6.

What is the primary phone number (include area code) to use for contact and leaving messages? *

7.

What is your marital / relationship status? *

8.

Please select the most accurate response to your eligibility to work in the USA, your residency, and your citizenship. *

9.

Please select the most accurate response to your experience in donating your eggs. *

10.

What is your date of birth? *

11.

Height *

12.

Weight *

13.

What is your highest level of completed education? *

14.

Have you completed egg donation cycles that have resulted in a pregnancy? *

15.

Is there anything in your history, the history of someone with whom you have been intimate, or with whom you live with, related to: *

16.

Is there anything in your history or the history of someone with whom you have been intimate, who has ever: *

17.

Which of the following have you had? *

18.

Please select the best answer related to smoking habits (including any form of nicotine products, including e-cigarettes). *

19.

When is the last time you have used other recreational drugs such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetamines, Hallucinogens, Tranquilizers (non-medical), PCP, Inhalants, Steroids (non-medical), Ecstacy, or other recreational drug for NON-MEDICAL purposes? *

20.

When is the last time you have had a non-medical needle piercing of your body (via acupuncture, tattoo, body piercing, ear piercing, etc.)? *

21.

What is the most number of consecutive days that you have been incarcerated? *

22.

Are your currently breastfeeding? *

23.

Have you taken a Depo Provero shot within the past year? *

24.

Do you have both ovaries? *

25.

Have you tested positive for Chlamydia or Gonorrhea within the last year? *

26.

Have you ever had any of the following? *

27.

Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other medical health professional for any reason? *

28.

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

29.

Are you adopted? *

30.

The next questions will be used to establish your username and password to be able to complete the overall application if your prescreen is approved. *

31.

Once you hit the submit button you will be taken to a page that allows you to enter the overall application. If your prescreen application was approved, you will automatically be able to log in and complete the overall application. Otherwise we are still evaluating your prescreen application. *


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)

4225 Executive Square, Suite 600, La Jolla, CA 92037 ♥ Phone 858.732.4277 (GBSS)  Fax 858.754.1225

www.greatbeginningssurrogacy.com