Fertile Friends Signup - Rochester

= 1 && substr($infertility_factors,0,1) == ‘;’) $infertility_factors = substr($infertility_factors,1); // Concat any contact options $contact_options = ”; if (isset($contact_phone)) $contact_options .= ‘;Phone’; if (isset($contact_email)) $contact_options .= ‘;Email’; if (isset($contact_im)) $contact_options .= ‘;Instant Messenger’; if (isset($contact_inperson)) $contact_options .= ‘;Meeting in Person’; if (isset($contact_other)) $contact_options .= ‘;Other (‘ . $contact_othernote . ‘)’; if (strlen($contact_options) >= 1 && substr($contact_options,0,1) == ‘;’) $contact_options = substr($contact_options,1); // Build the message $message = “\n\nThis is a sign up request – Fertile Friends – Rochester Office.\n\n”; $message .= “\n ” . “Date: $currdate”; $message .= “\n ” . “Age: $age”; $message .= “\n ” . “Email: $email”; $message .= “\n ” . “First name: $firstname”; $message .= “\n ” . “Last name: $lastname”; $message .= “\n ” . “Street: $street”; $message .= “\n ” . “City: $city”; $message .= “\n ” . “State: $state”; $message .= “\n ” . “Zip: $zip”; $message .= “\n ” . “Phone: $phone”; $message .= “\n ” . “Does age of match matter?: $age_matters”; $message .= “\n ” . “Marital status: $maritalstatus”; $message .= “\n ” . “Does marital status of match matter?: “.trim($ms_matters); $message .= “\n ” . “Does sexual orientation of match matter?: “.trim($so_matters); $message .= “\n ” . “How long trying to conceive?: $howlongtrying”; $message .= “\n ” . “Infertility factors: $infertility_factors”; $message .= “\n ” . “Contact options: $contact_options”; $message .= “\n ” . “How many Intra Uterine Insemination (IUI)?: $proc_iui”; $message .= “\n ” . “How many In Vitro Fertilization (IVF)?: $proc_ivf”; $message .= “\n ” . “How many Miscarriages?: $proc_miscar”; $message .= “\n ” . “Surgeries: $proc_surgeries”; $message .= “\n ” . “Children now? and how many?: $children”; $message .= “\n ” . “Biggest infertility hurdle: $hurdle”; $message .= “\n ” . “Personality description: $personality”; $message .= “\n ” . “Goal to acheive by participating in this program?: $goal”; $message .= “\n ” . “Prefer match to live locally?: $matchlocal”; $message .= “\n ” . “How should match tell you if she becomes pregnant?: $pregtell”; $message .= “\n ” . “Other notes/comments: $comments”; } ?>

Thank you for your interest in Fertile Friends in Rochester!‘; } if (isset($submit) && trim($submit) != ) // Form was submitted… { if (trim($age) != && trim($email) != && trim($firstname) != && trim($lastname) != && trim($street) != && trim($city) != && trim($state) != && trim($zip) != && trim($phone) != ) { mail(‘lstack@cnyfertility.com’,’Signup request – Fertile Friends – Rochester Office’,$message); print ‘Thank you!‘; print ‘Your Fertile Friends signup request has been sent to CNY Healing Arts.

‘; print ‘The program coordinator will contact you shortly!

‘; print ‘Click here to continue.

‘; return; // Exit the script. } else // Check for required fields. { print ‘

‘; if (trim($age) == ”) print ‘You forgot to type your age. Try again!’; else if (trim($email) == ”) print ‘You forgot to type your e-mail address. Try again!’; else if (trim($firstname) == ”) print ‘You forgot to type your first name. Try again!’; else if (trim($lastname) == ”) print ‘You forgot to type your last name. Try again!’; else if (trim($street) == ”) print ‘You forgot to type your street. Try again!’; else if (trim($city) == ”) print ‘You forgot to type your city. Try again!’; else if (trim($state) == ” || trim($state) == ‘NA’) print ‘You forgot to type your state. Try again!’; else if (trim($zip) == ”) print ‘You forgot to type your zip code. Try again!’; else if (trim($phone) == ”) print ‘You forgot to type your phone number. Try again!’; print ‘
‘; } } else // Full form was not submitted. { print ‘
Please complete this form to sign up!

* = Required field

‘; } ?>
By filling out and submitting this form I agree to allow CNY Fertility Center to act as coordinator between myself and another Fertile Friend participant in an effort to create a one-on-one support system for both of us. I agree to allow CNY Fertility Center to exchange my personal contact information with another participant and understand that NO medical information or history will be disclosed to participants. I release CNY Fertility Center of any liability for unforeseen incidents that could agree as a result of my participation in the Fertile Friends Program.
* Age: * Email address: * First name: * Last name: * Street: * City: * State:
* Zip: * Phone: Does the age of your match matter to you?: /> Yes
/> No
What is your marital status?: /> Married
/> Single
/> Non-Married Partner
Do you care about the marital status of your match?: /> Yes
/> No
Do you care about the sexual orientation of your match?: /> Yes
/> No
How long have you been trying to conceive?: What is your infertility factor? (Check all that apply): /> Male
/> Tubal
/> Uterine
/> Endometriosis
/> Polycystic Ovarian Syndrome
/> Diminished Ovarian Reserve
/> Tubal Ligation (not reversed)
/> Hydrosalpinx
/> Unexplained
/> Other How many of the following procedures have you undergone?:
Surgeries? (list them):
Do you have any children now? (if yes, please list them):
What is your biggest hurdle in dealing with infertility?:
How would you describe your personality? Are you outgoing, shy etc?
What is one goal that you would like to achieve through participating in this program?:
Which do you prefer to use for contact with your friend? (Check all that apply): /> Phone
/> Email
/> Instant Messenger
/> Meeting in Person
/> Other Would you prefer that your match live locally?:
/> Yes
/> No
If your match gets pregnant during the program or during treatment, how do you want her to tell you?:
Is there anything else that you would like to include?: