Fertility Scout Enrollment

Clinic / Sperm Bank Information

Name of Facility *

Type of Facility *

Fertility Clinic

Sperm Bank

Other(Please Describe)

Membership/Accreditation: *

ATTB

SART

If other please explain:

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 (This information will not be published to end users.)

First Name *

Last Name *

Email Address *

Phone # *

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.

Clinic / Sperm Bank Name *

Street Address *

Suite or Floor

City *

State *

Zip Code *

Practice URL *

Practice Phone # *

Practice Fax #

Physicians:

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

First Name

Last Name

Title

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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.

In order to participate your facility agrees to:

Designate a fertility preservation contact. (Provide information below.)

CONTACT THE PATIENT WITHIN 48 HOURS to set up the appointment

If a SART Clinic, adhere to the recommendations for fertility preservation programs identified by ASRM
Click here to view ASRM fertility preservation recommendations

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.

Title *

First Name *

Last Name *

Email Address *

Phone # *

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.

Are you a member of the Oncofertility Consortium’s National Physicians Cooperative (NPC)?

Yes

Is your facility a member of any other fertility preservation organizations or networks?

Yes

If Yes, please list:

Do you conduct fertility preservation research?

Yes

If Yes, please describe:

Clinic / Sperm Bank Information

Administrative Contact:

Location(s):

Physicians:

Add More

Online Referral Process:

Fertility Preservation Referral Contact:

Fertility Preservation Services:

Financial Assistance Services:

Fertility Preservation Activities: