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1. Do you have a fertility doctor?*
Yes, write the name of the doctor:
No, but would like a referral to a doctor in my area.

2. Do you know what type of treatment you are seeking? *
if Yes, select from menu
Not yet IVF Donor Egg IVF IUI Clomophine(Clomid) Ovarian Stimulation Gonadotropin Ovarian Stimulation Surgery Other

3. How soon do you anticipate starting treatment?*
Select one 1 month 2 months 3 months 4 or 5 months 6 to 8 months 9 to 11 months 12 to 18 months 18 months to 2 yrs 2yrs and above Not yet decided

4. I am interested in... (check any that apply)*
Affordable quality care and predictable pricing
Treatment financing and payment plan options
Refund Guarantee for Fertility Services
Referral to a board-certified Reproductive Endocrinologist
Other:

5. How did you first learn about us? (Answer all that apply)*
Physician or clinic/medical group referral: (indicate which one)
ARCfertility.com
Web search (Google, Yahoo, Ask)
Print advertisement, which:
Friend, word-of-mouth

6. To better assist you, any additional questions or comments are welcome (optional).
 

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