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Partner name *

Please complete partner information to expedite schedule. If you do not have a partner, please write n/a..

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if applicable

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I agree to the following: *

I understand this is a request form to become a patient at Fora Fertility for a semen analysis. A team member from Fora will be contacting me to establish care. If I live out of state, I understand that Fora Fertility only sees patients who are willing and able to travel to Austin, TX. Please mark "YES" to confirm you understand that Fora Fertility only sees fertility patients.

Yes