Waiting list Fertility Homeopath
Please fill in the form below to join the waiting list for a Fertility Assessment (PLUS) with Ingefleur. You will be contacted as soon as we have a slot available for you. *** Please note that when receiving an invitation you will have 48h to book after which slots will be offered to the next couple(s) on the waiting list and that fees are subject to change. ***
Email address *
Which type of appointment are you applying for? *
Name *
Date of birth *
MM
/
DD
/
YYYY
Full home address (street, number, postcode, city, country) *
Full name of partner *
Partner's date of birth *
MM
/
DD
/
YYYY
How long have you been trying to conceive? *
Please share a little bit (2-3 paragraphs or so) about your fertility journey so far and why you are looking for treatment with Ingefleur. *
Which of the following apply to you and your partner? *
You
Partner
Neither
Not applicable
(Past) use of steroids (including inhaler/cream/eye drops)
(Past) use of fertility drugs
(Past) use of contraceptives (select N/A for men)
History of labor drugs (select N/A for men)
(Past) silver/metal dental fillings
Have you and your partner completed or started any of Ingefleur's homeopathic detox protocols? If yes, which ones and according to which method? *
Anything you would like to add?
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Ingefleur.com. Report Abuse