Fertility Insight Session Form
Please take some time to enter the information in this form at the time of booking your appointment. If you have any questions, please email [email protected]. Applications without completed labs will not be accepted. Please submit results for Cycle Day 3 tests as requested below. If you do not have these tests completed within the last 6-12 months, please request from your doctor.
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Contact Information
Name*
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Email*
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Phone*
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Country*
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State*
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Date of Birth*
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Instagram Handle
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Your Partner's Details
Your Partner's Name*
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Partner Date of Birth*
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Your Partner's Email*
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Your Partner's Phone No.*
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Important
IT TAKES TWO TO MAKE A BABY! (Unless you're a #solomombychoice) Do you agree that your partner is on board?
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Partner Agrees to call other
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Are you ready and committed to doing what it takes?
Are you AND your partner (if you have one) are both on the same page about wanting a baby and getting the right support to get & stay pregnant?
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On a scale of 1-10 how ready do you (AND your partner) feel to have the guidance and support of an expert so you can stop Googling, and start putting your attention to the things that matter for your fertility outcomes. (1 = this is not a priority at the moment but will be in the future and 10 = Ready to invest right away into the right process that will help get results)
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How much are you willing to invest in the right process and fertility solution?
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Up to 10k = estimate cost of a decent program that will give you the first few steps on the journey (0 point)
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Up to 20k = estimate cost of a really well-experienced guide with a roadmap to your destination, who can personalize your journey with you
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Up to 30k = ~1 IVF cycle including meds
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Up to 120k = the average number of IVF cycles a couple goes through for success in research studies
Write anything you want to share about your fertility journey thus far. The more details, the better-- I will read it before our meeting
Fertility Journey*
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With regards to freedom/lifestyle, where are you currently and where would you like to be? (Be specific!)
Labs Cycle Day 3 Follicle
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Labs Cycle Day 3 Estradiol
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Labs Cycle Day 3 Luteinizing
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Cycle Day 3 Anti-mullerian Hormone (AMH)
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Semen Analysis results (be specific about the numbers) - please share count, motility, & morphology. We can review the rest in more detail later
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