Holistic Fertility Assessment Form
Please take some time to enter in the information in this form at the time of booking your appointment. Any questions, please email team@holisticfertilityinstitute.com.  Applications without completed labs will not be accepted. Please submit results for Cycle day 3 tests as requested below. If you do not have these tests completed within the last 6-12 months, please request from your doctor. 
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Email *
What's your name?  *
What is your phone number? *
What is your date of birth? *
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Your complete mailing address (including City, State, and Zip) *
What is your Instagram handle?
*
What's your partner's name?  *
Your partner's email address:  *
Your partner's phone number: *

Your partner's date of birth:

*
MM
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DD
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Your partner's complete mailing address:

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Public service announcement: IT TAKES TWO TO MAKE A BABY! (Unless you're a #solomombychoice)

Your partner needs to be on this call. Good with that? 

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IMPORTANT. 

Yes, Dr. Aumatma, WE ARE:  

1. Super committed to our future baby

2. Want to use a holistic approach to conception (solo or in combination with IVF/IUI)

3. Are willing to let go of pre-conceived notions around fertility & age, and instead let your team take the reins for a while to help us get to the major goal 

Note: Working with us isn't cheap but it's also not overly expensive considering 85% of our clients get and stay pregnant (even after having tried everything else that failed!). Should you want our help, it's not $50k but it's not $10k either. And, of course, we do offer payment plans and financing. 

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Cycle Day 3 Follicle Stimulating Hormone (FSH) *
Cycle Day 3 Estradiol *
Cycle Day 3 Luteinizing Hormone (LH) *
Cycle Day 3  Anti-mullerian Hormone (AMH) *
Semen Analysis results (be specific about the numbers) - please share count, motility, & morphology. We can review the rest in more detail later
Disclaimer: All information provided is for educational purposes only. It is not meant to substitute for the advice provided by your own physician or other medical professional. You are encouraged to consult with your health care provider prior to engaging in any protocols or consuming any supplements. None of the statements here are a recommendation as to how to treat any particular disease or health-related condition. If you suspect you have a disease or health-related condition of any kind, you should contact your health care professional immediately. *
A copy of your responses will be emailed to the address you provided.
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