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Fertility Application

Please fill out this application to the best of your ability. Once we receive your application we will send you an email with instructions for the next steps. 

Click the button below to start.

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Question 1 of 11

What is your name?

Question 2 of 11

What is your email address?

Question 3 of 11

What are you struggling with most when it comes to your health & fertility?

Question 4 of 11

On a scale of 1-10 how ready are you to find a solution to this problem right now? (1 being not at all important, 10 being very important)

Question 5 of 11

In an ideal situation how are you hoping this program will help you?

Question 6 of 11

What has worked well for you in the past?

Question 7 of 11

What has not worked well for you in the past?

Question 8 of 11

How much have you invested trying to solve this?

Question 9 of 11

Do you have a next step for fertility? If yes, what?

Question 10 of 11

Do you have someone that supports you in this?

Question 11 of 11

I sent over details of what's included & the investment options in the email that contained this application (Please look back on it if you missed it). On a scale of 1-10, how financially ready and able are you to make the investment to work with Dr. Beth? 

Confirm and Submit