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Oncofertility Professional Engagement Network Membership

Thank you for your interest in being a member of the Oncofertility Consortium through our Oncofertility Professional Engagement Network (OPEN).  In order to ensure that our Clinic/Center map is accurate for patients and providers that may access it, we request that you provide detailed information about your institution on an annual basis.

This includes contact information for any staff members involved in fertility preservation (MDs, PAs, nurses, lab staff, technicians, coordinators, researchers, and mental health professionals). To expand these fields, please click the links that apply.

If you have staffing or program changes throughout the year, feel free to email oncofert@msu.edu or re-submit this form.

To sign up for specific OPEN Subcommittees, complete the Subcommittee Participation form.

By submitting this form, you will subscribe all email addresses to quarterly newsletters and other periodic updates from the Oncofertility Consortium.

Membership Form
For a patient to call to schedule an appointment for a FP consult. Please specify if patient is to ask for someone specific.
Address
Address
City
State/Province
Zip/Postal
Country
Fertility Preservation Services Available to Your Patients
Please select what services are available at your clinic or institution. Select all services that apply.

Primary Clinical Contact

Name
Name
First
Last
Shipping Address
Shipping Address
City
State/Province
Zip/Postal
Country

Additional Clinical Contacts

Clinical Coordinator/Patient Navigator

Name
Name
First
Last
Mailing Address
Mailing Address
City
State/Province
Zip/Postal
Country

Additional Clinical Coordinator/Patient Navigator

Lab Contact

Name
Name
First
Last

Additional Lab Contact

Research Coordinator

Name
Name
First
Last

Additional Research Coordinator

Primary Nurse Contact

Name
Name
First
Last

Additional Nurse Contact

Physician Assistants

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