Eggtober - Generation Next Fertility

What is EGGTOBER?

In honor of Breast Cancer Awareness month, Generation Next Fertility is proud to present our EGGTOBER initiative. This initiative is to support women directly affected by breast cancer. We will be offering free egg freezing cycles to five (5) qualified candidates selected at random. Those not selected but still qualify will receive a discount.

At Generation Next Fertility, we strive to empower women by providing them with compassionate, individualized care. With EGGTOBER, we hope to help women fighting cancer to broaden their fertility choices. If you or someone you know is fighting breast cancer and is interested in our egg freezing initiative, kindly submit your application below.

Who is eligible?

Five (5) current or former breast cancer patients.
FREE procedure PLUS 1 YEAR of FREE storage.

The Eggtober Egg Freezing Initiative Will Cover:

Cancer dramatically changes lives,
let us help you keep your options for the future.

How to Apply:

To qualify for this program,

You must be at least 18 years old and currently or previously diagnosed with breast cancer.

Your oncologist must consent to your treatment.

If you meet the above conditions, please complete and submit the following forms before November 1st, 2022.

Step 1:

Have your Oncologist complete the
Oncologist Referral and Certification Form.

Download Now

Step 2:

Fill out the following online application form
and upload a scanned copy of the Oncologist Referral and Certification Form from STEP 1.

Terms & Conditions

Application Form opens October 1st!
Please have your Oncologist Referral and Certificate Form ready!

Eggtober Application Form October 2022

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 above prior to submitting this application. Questions can be addressed to our staff at Eggtober@GenerationNextFertility.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 November 1, 2022. 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.

Name *

First

Last

Email *

Phone *

Date of Birth *

Race/Ethnicity *

Address *

Street Address

Address 2

Street Address Line 2

City *

City

State *

State/Province

Zip *

Postal Zip Code

Date of Diagnosis *

Type of Cancer *

Name of Oncologist *

Oncologist/Hospital Phone Number *

Have you received any chemotherapy in the last six months? *

Are you aware of any reason that you are medically unable to participate in the egg retrieval process? *

Authorized Representative *

I authorize Generation Next to speak with the person listed below regarding my EGGTOBER application
I prefer that Generation Next only speak with me regarding my EGGTOBER application

Authorized Representative Contact

How did you hear about Eggtober? *

Completed Oncologist Referral and Certification Form Upload *

Click or drag a file to this area to upload.

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 *

I agree to the Terms and Conditions

https://www.generationnextfertility.com/terms-conditions/

Certificate of Accurate Completion *

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 Fertility, its representatives and/ or agents in order to assess my eligibility for participation in EGGTOBER program.

Please write your full, legal name to Sign Electronically *

Office Location

(Between Park Ave & Lexington Ave)

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Office Hours

Monday-Friday
7:00am – 5:00pm

Saturday
8:30am – 3:00pm

Sundays & Holiday Hours
By Appointment only

Monitoring Hours

Monday-Friday
6:45am – 12:00pm

Saturday
7:30am – 12:00pm

Sundays & Holiday Hours
By Appointment only

Application Form opens October 1st! Please have your Oncologist Referral and Certificate Form ready!

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Application Form opens October 1st!
Please have your Oncologist Referral and Certificate Form ready!