The Fertility Nurse: Exclusive Nurse - Phone Call Request Form

Request Free, No-Obligation Phone Call

Consulting and Research

“We can try to avoid making choices by doing nothing, but even that is a decision.”

- Gary Collins

Complete this form to request a free, no-obligation phone call to discuss setting up an exclusive nurse relationship.

The fields marked with an asterisks (*) are required. However, we recommend that you take the time to complete the whole form. The more complete the information you provide here, the better we can serve you on your call.

Information About You

*First name:

*Last name:

Date of birth:

(mm/dd/yyyy)

Male

Female

Information About Your Partner

First name:

Last name:

Date of birth:

(mm/dd/yyyy)

Male

Female

Your Address

Address Line 1:
Address Line 2:
City:
State:	(SS)
Zip code:	(XXXXX-XXXX)

Contact Information

Home Phone:
Daytime Phone:
Alternative Phone:
*Email:
*Enter email again to validate:
Best way to contact:

How Did You Hear About Us?

Friend

Physician or Fertility Specialist

Name of Physician:
Name of Clinic:

Where?

Internet

Where?

Other

Where?

Call Information

In the space below, prioritize the days and times that you have available for a phone call.

Based upon what you prioritize here, we will email to you three appointment options that are available in our schedule.

Specify days of the week and the periods (morning, afternoon, or evening) that work best. Include blackout dates or other notes regarding your availability that would help us select a convenient appointment time for you.

Reason(s) you are requesting an exclusive nurse:

Treatment Information

How long have you been attempting pregnancy?

Years

Months

Have you seen a fertility specialist?

Yes

Name of physician:

Name of clinic:

Diagnosis given:
Tests performed:
Treatments received:
Medications taken:

By submitting this request you are fully agreeing to this disclaimer.

Exclusive Nurse Services start at $2000/month. An exact price is established once we create a service plan that best matches your needs and desires.

All travel and miscellaneous expenses are approved and paid by you.

	Submit a request. Submit an online request for Exclusive Nurse Services.
	Talk with a coach to explore and define services. You will receive a no obligation, free phone call to discuss your situation. On this phone call, we will gather all the necessary information to create a custom Exclusive Nurse Service Plan.
	Receive an Exclusive Nurse Service Plan. You will receive via email a plan outlining a custom set of services based upon your needs and desires. The plan will also include a monthly fee commensurate with the services outlined.
	Receive an invoice. If you decide to move forward with the Exclusive Nurse Service Plan, you will receive an email invoice for the first month of services.
	Make payment. Click on the Payment Button in the email invoice to connect to a secure payment page. Make payment via Visa, MasterCard, American Express, Discover, eCheck, or a PayPal balance payment.
	Enjoy all the services of an Exclusive Nurse.


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For more information, contact the fertility nurse at (888) 245-8299 or

info@thefertilitynurse.com

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