Fertile Friends Signup - Albany

Thank you for your interest in Fertile Friends in Albany!
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?: Intra Uterine Insemination (IUI)
In Vitro Fertilization (IVF)
Miscarriage
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?: