Referring agency registration

Genetic Counseling Specialized for Reproductive Medicine

Agency/Bank details

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

Company name

Company address

Staff name(s)

Coordinator name (best point of contact)

Coordinator phone number

Coordinator email address

Emails (or fax, only if preferred) to send genetic risk reports for donors

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

YesNoConsidering it

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?

Do donors complete carrier screening while working with your agency/bank? If so, which carrier screening platform do you use for donors?

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

If donors have carrier screening with your company, do you also 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 often billed to the recipients at a cost of $200, but can also be covered under the invoice to your agency/bank, if preferred.

Billing preferences

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

Billing preferences

Invoice company for all visit typesHave recipients 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 invoices

Your company's practices and philosophies.

This is extremely helpful as we tailor our counseling to your company's workflow and philosophy. We like to make sure we support your team rather than bringing in additional complexities.

Any specific thoughts on how your company differs from others (in terms of donor selection, carrier screening philosophy, informed decisions for intended parents, other agency/bank-based decisions)?

Are there specific concerns about carrier screening, multifactorial disorders, or our philosophy on exclusion criteria? Please indicate if you'd like to schedule a chat with us in advance of counseling your clients.

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

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 subscribe to our newsletter to learn more about how genetics influences your work?

Yes, subscribe me to this newsletter

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