The AFA Physician Network Form

Name:

Practice:

Primary Office Address:

City:

State:
AlabamaAlaska ArizonaArkansasCalifornia ColoradoConnecticut District of ColumbiaDelaware FloridaGeorgiaHawaii IdahoIllinoisIndiana IowaKansasKentucky LouisianaMaineMaryland MassachusettsMichiganMinnesota MississippiMissouriMontana NebraskaNevadaNew Hampshire New JerseyNew MexicoNew York North CarolinaNorth DakotaOhio OklahomaOregonPennsylvania Rhode IslandSouth Carolina South DakotaTennesseeTexas UtahVermontVirginia WashingtonWest VirginiaWisconsin WyomingAlbertaBritish Columbia ManitobaNew BrunswickNewfoundland Northwest TerritoriesNova Scotia NunavutOntario Prince Edward IslandQuebec SaskatchewanYukon

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 Specialties or Services Performed at Your Practice:
2nd Opinions for Infertility
Acupuncture
Adolescent Gynecology
Advanced Laproscopy and Hysteroscopy
Age-Related Infertility
Andrology
Assisted Reproductive Technologies (ART)
Blastocysts
Clinical Genetics
Congenital Anomolies of Reproductive Tract
Donor Egg/Sperm
Egg Donation
Endocrinology
Endometriosis
Endoscopic Surgery
Genetics
Gynecology
HA
Hormone Effect on the Brain
Infertility
Inhiben B
IUI
IVF
IVF / ICSI
IVF Advanced Cases
Laser Infertility Surgery
Laser Laproscopy
Male Infertility
Male Urology
Maternal-Fetal Medicine
Menopause
Microsurgery
Microsurgical Reversal of Sterilization
Obstetrics
Ovulation Induction
Pathology
Patients over 40
PCOS
Pediatric
Pediatric Endocrinology
Pelvic Surgery
Peri-Menopause
Preimplantation Genetic Diagnosis (PGD)
Recurrent Pregnancy Loss
Relationship Issues
Reproductive Endocrinology
Reproductive Genetics
Reproductive Immunology
Reproductive Surgery
Stress Management
Surgery
Surgery for Congenital Anomalies
Third Party Reproduction
Tubal Obstruction Surgery
Urology
Uterine Fibroid Surgery
Uterine Fibroids
Women of Advanced Reproductive Age

Are You A Participant In Any Managed Care Plans?
No Yes <25% Yes 25% - 50% Yes >50%

Do You Have An Onsite Insurance Manager?
Yes No

Do You Treat Patients On A Fee-For-Services Basis?
Yes No

Education and Experience

Medical School & Year:
1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Residency & Year:
1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Fellowship & Year:
1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

OB/GYN & Year:
Board Eligible Board Certified 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Internal Medicine & Year:
Board Eligible Board Certified 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Urology & Year
Board Eligible Board Certified 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Reproductive Endocrinology & Year
Board Eligible Board Certified 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Endocrinology & Year:
Board Eligible Board Certified 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Other and Year:
1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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:

Other Membership:

Other Membership:

Are you a member in good standing with your State Board of Registry in Medicine?
Yes No

If no, please explain:

How did you first hear about this site?
Flyer in the Mail Brochure in Doctor Office Word of Mouth Clearblue Insert AFA Website Walgreens Search Engine Message Board Posting AFA E-Mail Flyer at AFA Symposium AFA Newsletter OV-Watch AFA Support Line Newspaper Ad The AFA Other

I understand my Resume / CV must be mailed to:

The American Fertility Association
Physician Network Application
315 Madison Avenue Suite 901
New York, NY 10017
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.

I understand that I will become a Professional Member of The AFA and will be invoiced for my level of membership accordingly.