Referring provider registration

Genetic Counseling Specialized for Reproductive Medicine

Practice and provider details

This form will help us tailor counseling to your patients and your clinic operations.

Practice name

Practice address

Physician name(s)

Coordinator name (best point of contact)

Coordinator phone number

Coordinator email address

Emails (or fax, only if preferred) to send genetic counseling reports

What is your carrier screening policy?

Which lab(s) do you use for carrier screening? Any specific platform?

If you have an example carrier screening report you could share, it would be helpful in determining counseling issues down the line with your clinic's patients. This is because platforms vary widely, and clinic-specific platforms are very common.

If you can, please upload an example carrier screening report.

Upload a File

Would you like us to work with gamete donors in your program?

YesNoConsidering it

Do you have an in-house donor program?

YesNo

Do you have a profile for each donor that can be shared with our team before a genetic counseling appointment?

Do donors have carrier screening prior to their genetic counseling appointment, or is this performed after the genetic counseling appointment?

Which carrier screening platform do you use for donors?

If you can, please upload an example carrier screening report for donors.

Upload a File

Do you routinely obtain a CBC with red cell indices and hemoglobin fractionation profile?

Recipients of gamete donation (intended parents) are encouraged to schedule a match consultation with our practice after the donor's appointment has been completed, if desired. This is usually billed to the recipients at a cost of $200.

Billing preferences

Invoice clinic for donor evaluations, but have patients self-pay for all other visit types (most common)Invoice clinic for all visit typesHave patients self-pay for all visit types (including donor evaluations-a bit more complicated logistically)Customized request for billing--please contact me

Billing preferences

Invoice clinic for all visit typesHave patients self-pay for all visit typesCustomized request for billing--please contact me

Billing contact

Invoices are sent via email; please share the best email for handling of clinic invoices, if appropriate

Your clinic's practices and philosophies.

This is extremely helpful as we tailor our counseling to your clinic and your physician(s). We like to make sure we support your practice rather than bringing in additional complexities.

Philosophy on PGT-A?

Are PGT biopsies done with in-house embryology staff?

Does your lab do blastocyst and/or Day 3 biopsy? If both, which is performed routinely?

Which lab(s) do you usually use for PGT-A and PGT-M/PGT-SR? Do you use a specific platform for PGT (i.e. array, NGS, SNP)?

What is your routine freezing tecnique?

Any specific thoughts on how your practice differs from others (in terms of ICSI utilization, culture to blastocyst stage, other practice-based decisions)?

Are there specific concerns about mosaicism, outcome data, etc., and decisions patients might be making? We are very comfortable with this literature, and focus on evidence-based patient decision-making. But it is also good to know how the physicians would like us to represent their philosophies and their willingness to transfer embryos at risk for mosaicism and embryos with aneuploidies. If the physician has a specific practice policy on these issues, we'd love to know about it in advance.

Are there specific concerns about mosaicism, outcome data, etc., and decisions patients might be making? Please indicate if you'd like to schedule a chat with us in advance of counseling your patients.

Do you have any PGT-related practice policies we should know about?

Do you refer for genetic counseling or testing for male infertility (sperm count below 10 million/mL)? Do you have the urologist handle this? Is there a urologist you partner with routinely?

Any other questions you have for our team? We will be sure to get back to you promptly.

Who filled out this form?

What is your email address?

example@example.com

Would you like to sign up for our newsletter to learn more about how genetics influences your practice?

Yes, subscribe me to this newsletter

Thank you for your time! We look forward to helping you and your patients.