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First Name
*
Last Name
*
Email Address
*
Which type of treatment cycle are you doing?
*
IUI (INTRAUTERINE INSEMINATION)
TIMED INTERCOURSE/ NATURAL RELATIONS
IVF
FET
EGG FREEZING
DONOR EGG - I AM THE INTENDED PARENT
DONOR EGG- I AM THE EGG DONOR
GESTATIONAL CARRIER/ SURROGATE - I AM THE INTENDED PARENT
GESTATIONAL CARRIER/SURROGATE - I AM THE CARRIER
OTHER
Clinic Name
*
Doctor/Prescriber Name
*
Are/were you or your partner in the military?
*
Yes
No
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?
*
Within 14 days from now
15 to 30 days from now
More than 30 days from now
I don't have treatment scheduled yet
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
Leuprolide Trigger 2 mg/40 unit
Leuprolide Trigger 4 mg/80 unit
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