Fertility Preservation Services Locator and Referral Tool


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.



Clinic / Sperm Bank Information:
Fertility Clinic
Sperm Bank
Other (Please Describe)
ATTB - This sperm bank is accredited by AATB
SART  - This clinic is a member of SART

Administrative Contact:

     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 (This information will not be published to end users.)  

Location(s):

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.
Physicians:

Please list the names of the physicians who provide fertility preservation services at the above location.

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.
 

Fertility Preservation Services:
Sperm banking for adults (on site)
Sperm banking for adolescents (under 18)(on site)
Sperm banking by mail available
Testicular sperm extraction ( biopsy)
Electroejaculation for semen collection:
Donor sperm
Long-term sperm storage
Embryo freezing
Egg freezing
Ovarian tissue freezing Yes No Donor Egg
Donor Embryo
Long-term egg and embryo storage
Long-term ovarian tissue storage
Yes No Yes No
Financial Assistance Services:

Do you participate in the following financial assistance programs for cancer patients?
Ferring / Walgreens Heart Beat Program
LIVESTRONG Fertility
Other (Please Describe)
Do not participate in any Fertility Preservation Financial Assistance Programs
Fertility Preservation Activities:

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.