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Date of Birth
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How did you hear about us?
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Searching Online (Google, Bing, etc)
Physician Referral
Word of Mouth (friend, family, etc)
Social Media (Instagram, Facebook, etc)
Insurance or Benefits Program
Billboard, Magazine, or Sign
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Event
Other
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Referring Physician
Write your referring Physician's Name
I am seeking an appointment to discuss
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Unexplained Infertility or Recurrent Pregnancy Loss
My reproductive health (fertility testing)
My reproductive health condition (PCOS, Endometriosis)
Freezing my eggs (Fertility Preservation)
Building a family (IVF, IUI, etc)
Building a family with the help of a donor (donor eggs, donor sperm, donor embryos)
Building a family with the help of a surrogate
Male Infertility (testing, fertility analysis)
LGBTQ+
2nd Opinion
Oncofertility
Other
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Person Account Record Type
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Lead Queue
Source ID
Contact ID
Lead ID
How did you hear about us?
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Online Search
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Friend or Family Referral
Insurance Carrier
Physician Referral
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Is your referring Physician an Ob/Gyn?
Yes
No
Were You Referred by a Physician?
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No
CampaignId
If you are ready to schedule your appointment, can you provide some additional details?
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Do you have insurance?
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No
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Insurance Provider
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Aetna
BCBS
Cigna
Humana
Progyny
Triwest
UHC
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Other Insurance Provider
Other Inquiry Type
Referring Patient
Employer Benefits
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Progyny
Maven Clinic
Stork Club
Carrot Fertility
Other
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Other Employer Benefits
Family/Friend Referral Name
Other "How did you hear about us?"
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Yes! Please send me news and offers about fertility from
Inception and its family of brands.
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