Price Quote Request

First Name *

Last Name *

Email Address *

Which type of treatment cycle are you doing? *

Clinic Name *

Doctor/Prescriber Name *

Are/were you or your partner in the military? *

As a current or former member of the military, you and/or your partner qualify for 10% or 50% off of Gonal-f, Cetrotide and Ovidrel through EMD Serono's Compassionate Care program. This is an income-based program. You MUST apply for Compassionate Care to receive this discount. Please visit our Compassionate Care page to apply.

When do you need these medications? *

Please indicate the quantity of each product that you need pricing on and leave products that you do not need blank. If the product you require is not on this list, please include the product name(s) and quantity in the "Other" box below.

	Cetrotide 0.25mg
	Clomid 50mg Tablet
	Crinone 8% gel
	Endometrin 100mg Insert
	Follistim AQ 300IU Cartridge
	Follistim AQ 600IU Cartridge
	Follistim AQ 900IU Cartridge
	Fyremadel 250mcg Prefilled Syringe
	Ganirelix Acetate 250mcg Prefilled Syringe
	Gonal-F Rff 300IU Pen
	Gonal-F Rff 450IU Pen
	Gonal-F Rff 900IU Pen
	Gonal-F 450IU Multi-dose Vial
	Gonal-F 1050IU Multi-dose Vial
	HCG 10,000U Vial (Pregnyl)
	"Lupron" Leuprolide 2 Week Kit 1mg/0.2ml
	"Lupron" Leuprolide Trigger 2 mg/40 unit
	"Lupron" Leuprolide Trigger 4 mg/80 unit
	"Lupron" Leuprolide Trigger 5 mg/100 unit
	Low Dose HCG 10 units/0.1ml
	Lupron Depot 3.75mg
	Menopur 75IU Vial
	Microdose Leuprolide 40mcg/0.1ml
	Microdose Leuprolide 40mcg/0.2ml
	Microdose Leuprolide 50mcg/0.2ml
	Novarel (HCG) 5000IU Vial
	Omnitrope 5.8mg Vial
	Ovidrel 250mcg
	Progesterone in Sesame Oil 50mg/ml
	Progesterone in Ethyl Oleate 50mg/ml
	Progesterone in Ethyl Oleate 100mg/ml
	Progesterone in Olive Oil 50mg/ml
	Zomacton 10mg

Other