FCI Donor Information Site - Donor Questionnaire

Please answer all of the questions and submit for processing.

After your information has been reviewed, you will receive a confirmation email with further instructions.

Thank you for taking the time to complete this Donor Questionnaire. If you have any further questions, please contact fcidonor@integramed.com.

Donor Questionnaire

Name (i.e. Jane Doe):

Email:

Email Confirmation:

Age:

Height:

Weight (lbs):

1. Are you a smoker?
YesNo

2. Do you have a GED or above?
YesNo

3. Are you a U.S. citizen with a SS #?
YesNo

4. Where you born in the United States?
YesNo

5. Do you live within 1 hour from an FCI location?
YesNo

1. Have you had any tattoos, body piercings or blood transfusions in the last 12 months?
YesNo

If yes, you will need to provide a letter of clearance.

2. Have you had a normal pap smear in the last 24 months?

YesNo

3. Can you commit to 8-10 required doctor visits as well as psychlogical and medical evaluations?
YesNo