{"id":144,"date":"2024-06-05T20:35:19","date_gmt":"2024-06-05T20:35:19","guid":{"rendered":"https:\/\/eggalliance.com\/?page_id=144"},"modified":"2024-06-17T16:07:35","modified_gmt":"2024-06-17T16:07:35","slug":"formor1","status":"publish","type":"page","link":"https:\/\/eggalliance.com\/?page_id=144","title":{"rendered":"FormOR1"},"content":{"rendered":"<div class=\"wp-block-uagb-container uagb-block-76f575f1 alignfull uagb-is-root-container\"><div class=\"uagb-container-inner-blocks-wrap\"><\/div><\/div><div class=\"wp-block-uagb-advanced-heading uagb-block-fcefd3cc\"><h2 class=\"uagb-heading-text\">Donated Egg Recipient Application Form<\/h2><\/div><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-b294aa9c-2a6b-4887-8ccd-6367ddc59079 wpforms-render-modern\" id=\"wpforms-102\"><form id=\"wpforms-form-102\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"102\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F144\" data-token=\"6f49712edcaa185f876849c2fafeba5e\" data-token-time=\"1781185990\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-102-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-102-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-102-field_1-error\" required><label for=\"wpforms-102-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-102-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-102-field_1-last-error\" required><label for=\"wpforms-102-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-102-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_27\">Birth Date (MM) <\/label><input type=\"text\" id=\"wpforms-102-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-102-field_27-error\" ><\/div><div id=\"wpforms-102-field_41-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_41\">Birth Date (YYYY)<\/label><input type=\"text\" id=\"wpforms-102-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-102-field_41-error\" aria-describedby=\"wpforms-102-field_41-description\" ><div id=\"wpforms-102-field_41-description\" class=\"wpforms-field-description\">19?? ~20??<\/div><\/div><div id=\"wpforms-102-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_3\">Email  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-102-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" spellcheck=\"false\" aria-errormessage=\"wpforms-102-field_3-error\" required><\/div><div id=\"wpforms-102-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_28\">Telephone Number<\/label><input type=\"text\" id=\"wpforms-102-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-102-field_28-error\" ><\/div><div id=\"wpforms-102-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_50\">Place of Birth<\/label><input type=\"text\" id=\"wpforms-102-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" aria-errormessage=\"wpforms-102-field_50-error\" ><\/div><div id=\"wpforms-102-field_51-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_51\">Are you a United States citizen or permanent resident?<\/label><select id=\"wpforms-102-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-102-field_63-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_63\">If not, what is your nationality?<\/label><input type=\"text\" id=\"wpforms-102-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63]\" aria-errormessage=\"wpforms-102-field_63-error\" ><\/div><div id=\"wpforms-102-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_53\">Ethniciity<\/label><input type=\"text\" id=\"wpforms-102-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-102-field_53-error\" ><\/div><div id=\"wpforms-102-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_7\">Height (cm \/ feet, inches)<\/label><input type=\"text\" id=\"wpforms-102-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-102-field_7-error\" ><\/div><div id=\"wpforms-102-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_11\">Weight (Kg\/Pounds)<\/label><input type=\"text\" id=\"wpforms-102-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-102-field_11-error\" ><\/div><div id=\"wpforms-102-field_66-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_66\">What is your current Gender?<\/label><select id=\"wpforms-102-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\"><option value=\"Female\"  class=\"choice-1 depth-1\"  >Female<\/option><option value=\"Male\"  class=\"choice-2 depth-1\"  >Male<\/option><option value=\"Other\"  class=\"choice-3 depth-1\"  >Other<\/option><\/select><div id=\"wpforms-102-field_66-description\" class=\"wpforms-field-description\">Female Male Other\r\n<\/div><\/div><div id=\"wpforms-102-field_31-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_31\">ABO Blood Types<\/label><select id=\"wpforms-102-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\"><option value=\"A\"  class=\"choice-1 depth-1\"  >A<\/option><option value=\"B\"  class=\"choice-2 depth-1\"  >B<\/option><option value=\"AB\"  class=\"choice-3 depth-1\"  >AB<\/option><option value=\"O\"  class=\"choice-4 depth-1\"  >O<\/option><option value=\"\u4e0d\u77e5\"  class=\"choice-5 depth-1\"  >\u4e0d\u77e5<\/option><\/select><div id=\"wpforms-102-field_31-description\" class=\"wpforms-field-description\">A B AB O \u4e0d\u77e5\r\n<\/div><\/div><div id=\"wpforms-102-field_32-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_32\">Rh Types<\/label><select id=\"wpforms-102-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\"><option value=\"Positive\"  class=\"choice-1 depth-1\"  >Positive<\/option><option value=\"Negative\"  class=\"choice-2 depth-1\"  >Negative<\/option><option value=\"Unknown\"  class=\"choice-5 depth-1\"  >Unknown<\/option><\/select><div id=\"wpforms-102-field_32-description\" class=\"wpforms-field-description\">Positive Negative Unknown\r\n<\/div><\/div><div id=\"wpforms-102-field_54-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_54\">Street Address<\/label><input type=\"text\" id=\"wpforms-102-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\" aria-errormessage=\"wpforms-102-field_54-error\" ><\/div><div id=\"wpforms-102-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_55\">City<\/label><input type=\"text\" id=\"wpforms-102-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-102-field_55-error\" ><\/div><div id=\"wpforms-102-field_68-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_68\">State<\/label><select id=\"wpforms-102-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\"><option value=\"AL\"  selected='selected' class=\"choice-1 depth-1\"  >AL<\/option><option value=\"AK\"  class=\"choice-9 depth-1\"  >AK<\/option><option value=\"AZ\"  class=\"choice-10 depth-1\"  >AZ<\/option><option value=\"AR\"  class=\"choice-11 depth-1\"  >AR<\/option><option value=\"CA\"  class=\"choice-12 depth-1\"  >CA<\/option><option value=\"CO\"  class=\"choice-13 depth-1\"  >CO<\/option><option value=\"CT\"  class=\"choice-14 depth-1\"  >CT<\/option><option value=\"DE\"  class=\"choice-15 depth-1\"  >DE<\/option><option value=\"FL\"  class=\"choice-16 depth-1\"  >FL<\/option><option value=\"GA\"  class=\"choice-17 depth-1\"  >GA<\/option><option value=\"HI\"  class=\"choice-18 depth-1\"  >HI<\/option><option value=\"ID\"  class=\"choice-19 depth-1\"  >ID<\/option><option value=\"IL\"  class=\"choice-20 depth-1\"  >IL<\/option><option value=\"IN\"  class=\"choice-21 depth-1\"  >IN<\/option><option value=\"IA\"  class=\"choice-22 depth-1\"  >IA<\/option><option value=\"KS\"  class=\"choice-23 depth-1\"  >KS<\/option><option value=\"KY\"  class=\"choice-24 depth-1\"  >KY<\/option><option value=\"LA\"  class=\"choice-25 depth-1\"  >LA<\/option><option value=\"ME\"  class=\"choice-26 depth-1\"  >ME<\/option><option value=\"MD\"  class=\"choice-27 depth-1\"  >MD<\/option><option value=\"MA\"  class=\"choice-28 depth-1\"  >MA<\/option><option value=\"MI\"  class=\"choice-29 depth-1\"  >MI<\/option><option value=\"MN\"  class=\"choice-30 depth-1\"  >MN<\/option><option value=\"MS\"  class=\"choice-31 depth-1\"  >MS<\/option><option value=\"MO\"  class=\"choice-32 depth-1\"  >MO<\/option><option value=\"MT\"  class=\"choice-33 depth-1\"  >MT<\/option><option value=\"NE\"  class=\"choice-34 depth-1\"  >NE<\/option><option value=\"NV\"  class=\"choice-35 depth-1\"  >NV<\/option><option value=\"NH\"  class=\"choice-36 depth-1\"  >NH<\/option><option value=\"NJ\"  class=\"choice-37 depth-1\"  >NJ<\/option><option value=\"NM\"  class=\"choice-38 depth-1\"  >NM<\/option><option value=\"NY\"  class=\"choice-39 depth-1\"  >NY<\/option><option value=\"NC\"  class=\"choice-40 depth-1\"  >NC<\/option><option value=\"ND\"  class=\"choice-41 depth-1\"  >ND<\/option><option value=\"OH\"  class=\"choice-42 depth-1\"  >OH<\/option><option value=\"OK\"  class=\"choice-62 depth-1\"  >OK<\/option><option value=\"OR\"  class=\"choice-43 depth-1\"  >OR<\/option><option value=\"PA\"  class=\"choice-44 depth-1\"  >PA<\/option><option value=\"RI\"  class=\"choice-45 depth-1\"  >RI<\/option><option value=\"SC\"  class=\"choice-46 depth-1\"  >SC<\/option><option value=\"SD\"  class=\"choice-47 depth-1\"  >SD<\/option><option value=\"TN\"  class=\"choice-48 depth-1\"  >TN<\/option><option value=\"TX\"  class=\"choice-49 depth-1\"  >TX<\/option><option value=\"UT\"  class=\"choice-50 depth-1\"  >UT<\/option><option value=\"VT\"  class=\"choice-51 depth-1\"  >VT<\/option><option value=\"VA\"  class=\"choice-52 depth-1\"  >VA<\/option><option value=\"WA\"  class=\"choice-53 depth-1\"  >WA<\/option><option value=\"WV\"  class=\"choice-54 depth-1\"  >WV<\/option><option value=\"WY\"  class=\"choice-55 depth-1\"  >WY<\/option><option value=\"AS\"  class=\"choice-56 depth-1\"  >AS<\/option><option value=\"DC\"  class=\"choice-57 depth-1\"  >DC<\/option><option value=\"GU\"  class=\"choice-58 depth-1\"  >GU<\/option><option value=\"MP\"  class=\"choice-59 depth-1\"  >MP<\/option><option value=\"PR\"  class=\"choice-60 depth-1\"  >PR<\/option><option value=\"VI\"  class=\"choice-61 depth-1\"  >VI<\/option><\/select><div id=\"wpforms-102-field_68-description\" class=\"wpforms-field-description\">AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS (American Samoa) DC (District of Columbia) GU (Guam) MP (Northern Mariana Islands) PR (Puerto Rico) VI (U.S. Virgin Islands)<\/div><\/div><div id=\"wpforms-102-field_56-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_56\">Zip Code<\/label><input type=\"text\" id=\"wpforms-102-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\" aria-errormessage=\"wpforms-102-field_56-error\" ><\/div><div id=\"wpforms-102-field_59-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_59\">Country: United State<\/label><select id=\"wpforms-102-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"Not\"  class=\"choice-9 depth-1\"  >Not<\/option><\/select><\/div><div id=\"wpforms-102-field_57-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_57\">Other Country<\/label><input type=\"text\" id=\"wpforms-102-field_57\" class=\"wpforms-field-medium\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-102-field_57-error\" ><\/div><div id=\"wpforms-102-field_5-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_5\">Eye Color<\/label><select id=\"wpforms-102-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\"><option value=\"\u68d5\u8272\"  class=\"choice-1 depth-1\"  >\u68d5\u8272<\/option><option value=\"\u85cd\u8272\"  class=\"choice-2 depth-1\"  >\u85cd\u8272<\/option><option value=\"\u9ed1\u8272\"  class=\"choice-3 depth-1\"  >\u9ed1\u8272<\/option><option value=\"\u7da0\u8272\"  class=\"choice-4 depth-1\"  >\u7da0\u8272<\/option><option value=\"\u6de1\u8910\u8272\"  class=\"choice-5 depth-1\"  >\u6de1\u8910\u8272<\/option><option value=\"\u7070\u8272\"  class=\"choice-6 depth-1\"  >\u7070\u8272<\/option><option value=\"\u7425\u73c0\u8272\"  class=\"choice-7 depth-1\"  >\u7425\u73c0\u8272<\/option><option value=\"\u5176\u5b83\"  class=\"choice-9 depth-1\"  >\u5176\u5b83<\/option><\/select><div id=\"wpforms-102-field_5-description\" class=\"wpforms-field-description\">Brown Blue Black Green Hazel Gray Amber Other<\/div><\/div><div id=\"wpforms-102-field_30-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_30\">Hair Color<\/label><select id=\"wpforms-102-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\"><option value=\"\u68d5\u8272\"  class=\"choice-1 depth-1\"  >\u68d5\u8272<\/option><option value=\"\u9ed1\u8272\"  class=\"choice-2 depth-1\"  >\u9ed1\u8272<\/option><option value=\"\u767d\u8272\"  class=\"choice-9 depth-1\"  >\u767d\u8272<\/option><option value=\"\u91d1\u8272\"  class=\"choice-4 depth-1\"  >\u91d1\u8272<\/option><option value=\"\u7d05\u8272\"  class=\"choice-5 depth-1\"  >\u7d05\u8272<\/option><option value=\"\u7070\u8272\"  class=\"choice-6 depth-1\"  >\u7070\u8272<\/option><option value=\"\u8d64\u8910\u8272\"  class=\"choice-7 depth-1\"  >\u8d64\u8910\u8272<\/option><option value=\"Other\"  class=\"choice-8 depth-1\"  >Other<\/option><\/select><div id=\"wpforms-102-field_30-description\" class=\"wpforms-field-description\">Black Brown White Blonde Red Gray Auburn Othe<\/div><\/div><div id=\"wpforms-102-field_29-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_29\">What is your relationship status?<\/label><select id=\"wpforms-102-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\"><option value=\"Spouse\"  class=\"choice-1 depth-1\"  >Spouse<\/option><option value=\"Friend\"  class=\"choice-2 depth-1\"  >Friend<\/option><option value=\"SIngle\"  class=\"choice-3 depth-1\"  >SIngle<\/option><option value=\"Other\"  class=\"choice-4 depth-1\"  >Other<\/option><\/select><div id=\"wpforms-102-field_29-description\" class=\"wpforms-field-description\">Who do you live with? Spouse Friend Single Other<\/div><\/div><div id=\"wpforms-102-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_14\">Are you willing to accommodate the schedule of a fresh egg donor?<\/label><select id=\"wpforms-102-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"Unknown\"  class=\"choice-3 depth-1\"  >Unknown<\/option><\/select><\/div><div id=\"wpforms-102-field_60-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_60\">Are you open to receiving frozen eggs?<\/label><select id=\"wpforms-102-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"Unknown\"  class=\"choice-3 depth-1\"  >Unknown<\/option><\/select><\/div><div id=\"wpforms-102-field_65-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_65\">Will you require the egg donor to undergo genetic screening for hereditary diseases?<\/label><select id=\"wpforms-102-field_65\" class=\"wpforms-field-medium\" name=\"wpforms[fields][65]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"Unknown\"  class=\"choice-3 depth-1\"  >Unknown<\/option><\/select><\/div><div id=\"wpforms-102-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_22\">Do you have any other specific traits or conditions you require from the egg donor?<\/label><textarea id=\"wpforms-102-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-102-field_22-error\" ><\/textarea><\/div><div id=\"wpforms-102-field_15-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_15\">Do you drink?<\/label><select id=\"wpforms-102-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"Occasionally\"  class=\"choice-4 depth-1\"  >Occasionally<\/option><\/select><div id=\"wpforms-102-field_15-description\" class=\"wpforms-field-description\">Yes No Occasionally<\/div><\/div><div id=\"wpforms-102-field_35-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_35\">Do you smoke?<\/label><select id=\"wpforms-102-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"Occasionally\"  class=\"choice-4 depth-1\"  >Occasionally<\/option><\/select><div id=\"wpforms-102-field_35-description\" class=\"wpforms-field-description\">Yes No Occasionally<\/div><\/div><div id=\"wpforms-102-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_38\">What is your highest level of education?<\/label><input type=\"text\" id=\"wpforms-102-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-102-field_38-error\" ><\/div><div id=\"wpforms-102-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_39\">What is your current occupation?<\/label><input type=\"text\" id=\"wpforms-102-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" aria-errormessage=\"wpforms-102-field_39-error\" ><\/div><div id=\"wpforms-102-field_33-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_33\">Had you ever had Surgery\uff1f<\/label><select id=\"wpforms-102-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\"><option value=\"Yes\"  class=\"choice-5 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-8 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-102-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_9\">If yes, what surgery you had before\uff1f<\/label><input type=\"text\" id=\"wpforms-102-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-102-field_9-error\" ><\/div><div id=\"wpforms-102-field_42-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_42\">Do you have adenomyosis, myoma, or endometriosis now?<\/label><select id=\"wpforms-102-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\"><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-102-field_43-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_43\">Had you have operation of cervical ionization or history of cervical incompetency ? <\/label><select id=\"wpforms-102-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-102-field_40-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_40\">Had you history of getting cancer\uff1f<\/label><input type=\"text\" id=\"wpforms-102-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-102-field_40-error\" ><\/div><div id=\"wpforms-102-field_67-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_67\">Do you need surrogacy\uff1f<\/label><select id=\"wpforms-102-field_67\" class=\"wpforms-field-medium\" name=\"wpforms[fields][67]\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-102-field_44-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_44\">Do you have DM, hypertension, autoimmune disease or other Internal medicine diseases? <\/label><select id=\"wpforms-102-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-102-field_64-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_64\">If yes, what Internal medicine diseases you have?<\/label><input type=\"text\" id=\"wpforms-102-field_64\" class=\"wpforms-field-medium\" name=\"wpforms[fields][64]\" aria-errormessage=\"wpforms-102-field_64-error\" ><\/div><div id=\"wpforms-102-field_46-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_46\">Have you ever used or injected any recreational drugs or illegal drugs? (Cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinations, tranquilizers, PCP, steroids, or others.)<\/label><select id=\"wpforms-102-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-102-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_45\">If yes, which drugs, and when were they last used?<\/label><input type=\"text\" id=\"wpforms-102-field_45\" class=\"wpforms-field-medium\" name=\"wpforms[fields][45]\" aria-errormessage=\"wpforms-102-field_45-error\" ><\/div><div id=\"wpforms-102-field_26-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_26\">Are you currently taking any medications?<\/label><select id=\"wpforms-102-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-102-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_47\">If yes, please provide the name and indication.<\/label><input type=\"text\" id=\"wpforms-102-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\" aria-errormessage=\"wpforms-102-field_47-error\" ><\/div><div id=\"wpforms-102-field_48-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_48\">Have you ever been seen by a psychologist, psychiatrist, social worker, counselor, or any other medical health professional for any reason?<\/label><select id=\"wpforms-102-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-102-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-102-field_49\">If yes, for how long and what reason?<\/label><input type=\"text\" id=\"wpforms-102-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-102-field_49-error\" ><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"102\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/eggalliance.com\/index.php?rest_route=\/wp\/v2\/pages\/144\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-102\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/eggalliance.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container 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