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 (This information will not be published to end users.)
Online Referral Process:
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.
Fertility Preservation Referral Contact:
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.
© 2017 Alliance for Fertility Preservation. All rights reserved. Email: firstname.lastname@example.org
Tel: (415) 535-6088