Irregular Periods, Painful Sexual Intercourse, Miscarriage, PCOS, Pelvic Adhesions, Hirsutism

IS FERTILITY TREATMENT RIGHT FOR YOU?

Infertility affects more than 5.3 million Americans. With proper treatment administered by board-certified reproductive endocrinologists, many couples facing fertility challenges can successfully achieve pregnancy.

If you are thinking about seeking help from a fertility specialist, we invite you to take our survey. The following 9 questions will help determine if pursuing fertility treatment is right for you and your family. If you give us permission, we will contact you to discuss your concerns.

Javascript is not currently enabled on your browser. If you can enable it, your input will be checked as you enter it (on most browsers, at least). You may find this helpful. Nevertheless, this form will still submit as long as ALL fields are filled in.

First Name*:
Last Name*:
Street Address*:
City*:
State*:
Zip Code*:
Telephone*:
Age*:
E-Mail*:
May we leave a message?*:
Best time to contact*:
How did you hear about us?:
May we send you an email?:

Survey

Have you gone more than six months without using contraception? Yes No
Do you have uncomfortable, painful, or irregular menses or menstrual cramps? Yes No
Have you ever been treated for abdominal pain or had abdominal /pelvic surgery, such as appendix removal or Cesarean section? Yes No
Do you have painful sexual intercourse? Yes No
Do you have acne, hirsutism (abnormal hair growth) or been told you have PCOS? Yes No
Have you had any pregnancy losses or miscarriages? Yes No
Have you tried to get pregnant unsuccessfully or been treated for infertility? Yes No
Have you previously undergone treatment with in-vitro fertilization (IVF)? Yes No
Are you aware of financing options for fertility treatments if you do not have insurance coverage? Yes No

If you have any specific questions for our physicians, please ask them below:

* All fields are required