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Are you between the ages of 21-45?
Yes
No
Have you given birth to at least one child?
Yes
No
First Name:
Last Name:
Do you Smoke
Yes
No
Do you use Illegal Drugs?
Yes
No
What's your Email:
Are you willing to take medications prescribed by the fertility clinic?
Yes
No
Do you love being pregnant?
Yes
No
Do you want to give the gift of parenthood to a loving and deserving couple?
Yes
No
What's your phone number? (no spaces or dashes)
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