Name of Clinic
*
I would like to:
Your Name
*
We'd like to know who submitted this form so we have a point of contact if we need to confirm any information. Your name will not be displayed publicly.
First Name
Last Name
Your Phone
Your business phone - a direct line, if possible. This will not be displayed publicly, but will be used for communication if the Freeze team has additional questions on your profile.
(###)
###
####
Which blood tests do you require before a cycle starts?
*
Are the costs for these blood tests included in in the price of the first consultation?
*
Remember to assume that this is a cash-paying, uninsured patient.
Do you require an ultrasound before a cycle starts?
*
Are there any other costs that may be incurred before a cycle starts?
Examples may include additional consults, additional cost for longer appointments, equipment fees, fees for in-office venipuncture or laboratory fees that are not included in the lab test cost above, etc. Please list, including pricing (provide range if pricing is variable) and whether this is required cost for all patients, or optional. (If any costs are optional, please explain in what circumstances it may be recommended or required.)
Is there any other information about the process and fees leading up to a cycle start that patients should be aware of?
How much does a single cycle of egg freezing cost?
*
Are there any other costs that may be incurred during a cycle?
Examples may include monitoring costs, additional cost for longer appointments, equipment fees, facility fees, etc. Please list, including pricing (provide range if pricing is variable) and whether this is required cost for all patients, or optional. (If any costs are optional, please explain in what circumstances it may be recommended or required.)
Is there any other information about the process and fees of a single cycle that patients should be aware of?
Does your clinic offer onsite storage?
*
Are there any additional costs that may be incurred after the cycle has ended?
Examples may include additional follow-up consults, blood work, ultrasounds, etc. Please list, including pricing (provide range if pricing is variable) and whether this is required cost for all patients, or optional. (If any costs are optional, please explain in what circumstances it may be recommended or required.) Please exclude costs for when a patient may come back to unfreeze her eggs.
Is there any other information about the process and fees after a woman has completed her cycle that she should be aware of?
Do you offer discounts on any additional cycles?
If so, please explain these discounts and any exclusions or terms that are associated with them. (For example, $1,000 discount on two cycles if a woman prepays for both; $500 discount if a woman comes back for a second cycle in the next six months, etc.)
Do you have a preferred long term storage vendor? Who is it and how much does it cost for one year?
How many egg freezing cycles has your clinic performed?
*
How many eggs from your clinic have been thawed for the purpose of implantation?
*
How many pregnancies have resulted from those thawed eggs?
*
Please provide links to your clinic's social media accounts.
We like to be social! We'll follow you from our accounts, and link to your social media accounts from your listing on the Freeze site so our community can find you there, too.
What is your clinic's mailing address?
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you see patients at this address? Do you have additional locations?
*
If you have more than one location where you see patients, the Freeze team will email you to collect the addresses of your additional locations.
Would your clinic be willing to discuss offering a discount or promotion to the Freeze community for egg freezing at your clinic?
