The Fertility Nurse: One-Time Coaching - Phone Call Request Form

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

- Gary Collins

Complete this form to request a One-Time Coaching Call.

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 coaching call.

Call Urgency

*Do you require a coaching call within the next 24 hours?

Yes

PLEASE NOTE:

If you require a coaching call within the next 24 hours, submit this form and call us immediately at (888) 245-8299 and dial extension 704. A coach will set a coaching call appointment with you. The appointment will be within 24 hours of the time you made the request. A 50% surcharge is added if you require a call within 24 hours of your request.

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?

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:

Call Information

*Describe in detail what you wish to discuss during your coaching call.

What are your goals for the call? Or if this call were a success, what would you know or feel or experience after the call that you do not know or feel or experience now?

Estimate how long this phone call will last (minutes):

PLEASE NOTE:

We will schedule a call with you based upon your estimate here.

Keep in mind that due to other appointments in our schedule, your coaching phone call will need to end within 5 minutes of the time you estimate here. If you desire more time with your fertility coach, a second call can be scheduled with her at the end of your call.

One-Time Coaching Calls are billed in 15 minute increments. Thus, if the time you have estimated here is longer than the actual time used by 15 minutes or greater, you will receive a refund for the unused time.

If you are unable to estimate the time, you can leave the estimate blank. We will send an invoice based upon our best estimate. Unused time will be refunded.

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

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.

By submitting this request you are fully agreeing to this disclaimer and to the costs and terms associated with One-Time Coaching.

One-Time Coaching is billed at $145 per hour in 15 minute increments. A 50% surcharge is added if you require a call within 24 hours of your request.

If after your coaching call you are not satisfied for any reason, we will provide a full refund.

	Schedule a call. Submit an online request for a One-Time Coaching Call. You will be asked to prioritize the days of the week that work best for you and whether the mornings, afternoons, or evenings work best. We will also ask you to estimate the amount of time you want to spend with a fertility nurse and to list any blackout dates and times that are not available on your calendar.
	Set an appointment. You will receive an email from us that suggests at least three appointment times. Respond to this email with your appointment selection.
	Receive an invoice. You will receive an email invoice for the amount of time you estimated the One-Tine Call will take.
	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.
	Call your coach at the appointed time. Make the call to your fertility nurse at the scheduled time.


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

info@thefertilitynurse.com

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