Fertility Freedom - Patient Referral

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I'm honored you're interested in including my work in your patient's care ✧ Please fill out this form below so I may learn more about your patient, their goals, and your goal for them. I'll respond do you within 48 business hours to debrief if it feels like a supportive match.

Your name + credentials

Your email

Your practice / business name

What is your patient's demographic (age, gender)

What are the goals of your patient? Please check all that apply.

Avoid pregnancy

Conception

Learn to track and chart their menstrual cycle

Strengthen their hormone production

Identify their unexplained infertility

Other:

What are their related symptoms + diagnoses?

What are your goals for your patient in working with me?

Is there anything else you would like me to know?

Submit

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