The American Fertility Association

Name:

Practice:

Primary Office Address:

City:

State:

Zip:

Business Phone:

E-Mail:

Web Address:

Names of Associates:

Additional Offices:

Practice:

ART Program Affiliation:

ART Program Address:

Hospital Affiliations:

Specialty Area For Resource Directory Listing:

Please Check All That Apply To Your Speciakties:

Age Related Infertility:
Andrology / Microsurgery:
Congenital Anomalies of Reproductive Tract:
Cryopreservation:
Endometriosis:
Fertility Preservation In Cancer & Surgery Patients:
GIFT:
IUI:
IVF:
Male Infertility:
Male Microsurgery:
Maternal-Fetal Medicine:
Myomectomy:
Ovulation Induction:
Ovum Donation:
PCOS:
Peri-Menopause:
PGD:
Recurrent Miscarriage:
Reproductive Surgery:
Sexual Dysfunction:
Third Party Reproduction:
Tubal Re-Anastamosis:

Please Check All Services Performed At Your Practice:

Reproductive Endocrinology:
Reproductive Surgery:
In Vitro Fertilization:
ICSI:
Donor Egg:
Donor Egg Single Woman:
Donor Sperm:
Donor Sperm Single Woman:
Urology Female:
Urology Male:
PCOS:
Gynecologist:
Obstetrician/Gynecologist:
High Risk Ob/Gyn:
Menopause:
Psychotherapist on Staff:
Alternative Therapies:
Other:

Are You A Participant In Any Managed Care Plans?

Do You Have An Onsite Insurance Manager?

Do You Treat Patients On A Fee-For-Services Basis?

Education and Experience

Medical School & Year:

Residency & Year:

Fellowship & Year:

OB/GYN & Year:

Internal Medicine & Year:

Urology & Year

Reproductive Endocrinology & Year

Endocrinology & Year:

Other and Year:

Professional Memberships:

Professional Member of The AFA:
ASRM - Society for Assisted Reproductive Technology:
ASRM - Society of Reproductive Surgeons:
ASRM - Society of Reproductive Endocrinologists:
ASRM - Society of Reproductive Urologists:

Other Membership:

Are you a member in good standing with your State Board of Registry in Medicine?

If no, please explain on a separate piece of paper.

How did you first hear about this site?

I understand my Resume / CV must be mailed to:

The American Fertility Association
Physician Network Application
305 Madison Avenue Suite 449
New York, NY 10165
Tel: (888) 917-3777

“I acknowledge and agree that my inclusion or removal from The AFA Physician Network list is at The AFA’s sole discretion. Furthermore, in consideration of my inclusion on the list, I agree to indemnify, defend and hold The AFA harmless in the event a patient referred to me by The AFA makes a claim against The AFA, its directors, employees, members and volunteers, in connection with services rendered by me or my practice.”