Welcome to the Alliance’s submission system. Please take a few minutes to complete the form below with current information about
your clinic or sperm bank, to ensure that oncologists and patients looking for fertility preservation services can find you.
Please list the name and contact information for the person who is managing your facility's participation in this tool.
This is for the Alliance's internal use, so that we can follow up with you about your information, if necessary.
(This information will not be published to end users.)
If your facility has multiple locations, you must complete separate entries for each location. This tool is based on
a map system, so that end users can see each of your locations and select the one that is most convenient. Please
only list the physicians/staff and the services that are associated with the individual location.
Please list the names of the physicians who provide fertility preservation services at the above location.
By submitting your clinic’s information, your practice is agreeing to accept online referrals/appointment requests
from oncology professionals and patients. All referrals are transmitted and stored on encrypted, HIPAA compliant
servers. This system is designed to expedite the scheduling process for cancer patients who need fertility preservation
services on an emergency basis.
Please identify the person within your practice who triages fertility preservation patients. *This is the person within
your practice who will receive email alerts for all referrals coming through the system*
The below named Fertility Preservation Contact will:
Receive an email notification of a new referral; 2. Sign in to a secure portal to view the patient information; and
3. Contact the patient within 48 hours to set up an appointment.
Do you participate in the following financial assistance programs for cancer patients?
Please use this opportunity to describe your practice’s fertility preservation experience/activities. This text will
appear on your profile page and is designed to allow you to speak directly to the oncologists and cancer patients
who are considering your facility.