Customer Survey Participants Application

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Thank you for your interest for Fertility Counselling Survey Campaign.

Lumirous is helping couples who suffers from infertility.
Please check our website to understand us more: https://www.lumirous.com

We would like you to experience our service and get your feedback to improve.

[Am I qualified to join the survey?]
Malaysian citizen, who can communicate in English with the back ground following below
-A person or couple who have done infertility treatment
-A person or couple who are having fertility treatment
-A person or couple who are struggling with infertility
-A person or couple who have have started to trying to conceive

[Customer Survey Steps]
(1) Fill in the Consultation Form
(2) Take Free 15mins Online Counselling with Fertility Counsellor in June 2021
(3) Answer the Survey
(4) 15mins Interview with LUMIROUS staff
(5) LUMIROUS provide RM20 Grab Gift Card as appreciation
*Only for those who complete section (1)~(4).

Email *

Name (Full Name) *

Gender *

Female

Male

Other:

Age *

Malaysian Mobile Number(WhatsApp) +60(0)xx-xxx-xxxx *

Nationality *

Malaysian (Malay)

Malaysian (Chinese)

Malaysian (Indian)

Malaysian (Other)

Other:

Tell me about yourself *

I have done the infertility treatment in clinic (IVF, IUI, etc )

I am under the infertility treatment

I have been trying to conceive a baby, but nothing is happening (more than 6months)

I have tried to conceive, but gave up

I want to get a baby but, but not sure what to do

Other:

Required

Your interest to know

Best Food for fertility

Best Excersise for Fertility

Basic knowledge about Fertility (Common case for infertility, How to use basal temperature, How to use ovulation test kit)

IVF (Price, Process and Experience, etc)

Sperm test / Female pregnancy check (Preparation test)

Tips on Communication with partners

Other:

What is your pregnancy struggle story about? Tell us about your story. *

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