Kofinas Fertility Group Egg Donor Application
Your first step toward becoming an egg donor at Kofinas Fertility Group!
Email address *
First Name *
Your answer
Last Name *
Your answer
Phone number *
Your answer
Address
Your answer
City
Your answer
Do you live within 50 miles of Brooklyn?
Do you have reliable transportation?
Are you able to come in for a period of 8-10 days in a row for monitoring/injection appointments?
What is your age? *
Your answer
What is your height? *
Your answer
What is your weight? *
Your answer
What is your ethnic background? *
Your answer
Highest level of education received? *
Are you currently enrolled in school? *
Date of last menstrual period? *
MM
/
DD
/
YYYY
Do you currently smoke? *
Do you drink alcohol
Do you currently have any medical problems?
Do you have a history of medical conditions/problems? *
Does anyone in your family have a history of medical conditions/problems? *
Do you have a history of mental disorders? *
Does anyone in your family have a history of mental disorders? *
Are you currently on birth control? *
Have you donated eggs in the past? *
Have you ever been pregnant before? *
Have you ever been treated for infertility? *
Have you ever been treated for endometriosis? *
How did you hear about our program? *
Your answer
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