To be eligible for the Eggtober program offered by Generation Next Fertility, PLLC (“Generation Next”), you must be over the age of 18, have a cancer diagnosis and not have received chemotherapy in the last six months. Please read the terms and conditions located at https://www.generationnextfertility.com/terms-and-conditions/ before submitting this application. Questions can be addressed to Jacqueline Kirstein at email@example.com
Complete all fields in the following form and keep a copy for your records. Incomplete applications will not be processed. To be considered, applications must be submitted prior to October 31, 2018.
Note: If you are selected, a physician will discuss the risks, side effects and other aspects of all treatment options with you before recommending the best course of treatment. If at any time you are advised to seek treatment for cancer immediately, it is our position that you should not delay cancer treatments in order to receive these fertility preservation services.
|First Name:||Middle Name:|
|Primary Phone:||Secondary Phone:|
|Race/Ethnicity:||Date of Birth:|
|Cancer Type:||Date of Diagnosis:|
|Name of Oncologist:||Phone Number:|
Have you received any chemotherapy in the last six months? ☐ YES ☐ NO
Are you aware of any reason that you are medically unable to participate in the egg retrieval process? ☐ YES ☐ NO
AUTHORIZED REPRESENTATIVE (check one)
☐ I authorize Generation Next to speak with the person list below regarding my Eggtober application:
|☐ I prefer that Generation Next only speak with me regarding my Eggtober application|
APPLICANT CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION
☐ By checking this box, I certify that the information provided in this application is complete and accurate. I authorize the release of the information contained in this application. I understand it is for the sole use of Generation Next, its representatives and/ or agents in order to assess my eligibility for participation in Eggtober program.
PLEASE SUBMIT THIS APPLICATION AND THE ONCOLOGIST CONSENT FORM TO:
You will receive an email confirming Generation Next receipt of this application. Please check your junk and spam folder for your notification as it tends to filter into there at times.
Your signature below certifies that you have completed all of the above sections completely, accurately, and to the best of your knowledge, and that you have read, understand, and agree to the terms and conditions of this application.
|PATIENT SIGNATURE:||DATE / /|
* This form is not a prescription.