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Oncologist Referral Form

Oncologist Referral Form 2018-09-29T21:13:15+00:00

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Eggtober Program

Oncologist Referral and Certification Form

This Referral and Certification form is to be used to evaluate the eligibility of the patient listed below to participate in the Eggtober program sponsored by Generation Next Fertility, PLLC (“Generation Next”).   This program allows for selected applicants to receive complimentary oocyte (egg) extraction, cryopreservation and storage services for three months.   In order to be eligible, applicants must:  (1) have a breast cancer diagnosis; (2) have not have received chemotherapy for six months; and (3) be otherwise free from any conditions that would limit the egg extraction.   Please complete the attached form to confirm this applicant’s eligibility.  All fields need to be completed. Incomplete applications will not be processed.

Note: You should discuss the risks, side effects and other aspects of all treatment options with your patient before recommending the best course of treatment. If at any time you have advised or do advise your patient to seek treatment for cancer immediately, it is the position of Generation Next that the patient should not delay treatments in order to receive these services.

PATIENT INFORMATION

Last Name:

     

First Name:

     

Middle Name:

     

Date of Birth:

     

Primary Phone:

     

PHYSICIAN INFORMATION

Last Name:

     

First Name:

     

MI:

     

Title:

     

Street Address:

     

City:

     

State:

     

Zip Code:

     

Phone:

     

Fax:

     

Email:

     

TREATMENT INFORMATION

Cancer Type:

     

Date of Diagnosis:

     

TREATMENT PLAN

Surgery to the reproductive area (explain below)

Chemotherapy

Radiation to the brain or reproductive area

Other (explain below)

TREATMENT TIMELINE

(should fall after completion of fertility treatment)

Estimated State Date:

     

Date Range of Treatment:

     

FOR THE FOLLOWING STATEMENT, CHECK YES OR NO

Answer is required; incomplete answers will delay processing.

Does the above described treatment plan present a risk of infertility to the patient?

Yes  No

ACKNOWLEDGEMENT

I have discussed with the patient the risks, side effects and other aspects of all her treatment options. I certify that in my medical judgement there is no reason that the above-named patient should not undergo ovarian stimulation and oocyte retrieval as prescribed by a reproductive endocrinologist for purposes of fertility preservation.

ONCOLOGIST SIGNATURE:

     

Date: