Patients
How can PGT help me?
How & When is PGT Performed
Genetic Counseling for PGT
Affordable Testing
Find an IVF Clinic
Providers
How Can PGT Help My Patients
How & When is PGT Performed
Embryology Services
Refer a Patient
Resources /Published Works
Tests
PGT-A
PGT-M
PGT-SR
PGT-HLA
Services
Cryobank
IVF Lab
Embryology
Andrology
Cryobank
PGT Lab
PGT-A
PGT-M
PGT-SR
PGT-HLA
Genetic Counseling for PGT
Personalized Billing
About Us
Why RGI
Our Team
Careers
Resources
Contact Us
Blog
Portal
Patients
How can PGT help me?
How & When is PGT Performed
Genetic Counseling for PGT
Affordable Testing
Find an IVF Clinic
Providers
How Can PGT Help My Patients
How & When is PGT Performed
Embryology Services
Refer a Patient
Resources /Published Works
Tests
PGT-A
PGT-M
PGT-SR
PGT-HLA
Services
Cryobank
IVF Lab
Embryology
Andrology
Cryobank
PGT Lab
PGT-A
PGT-M
PGT-SR
PGT-HLA
Genetic Counseling for PGT
Personalized Billing
About Us
Why RGI
Our Team
Careers
Resources
Contact Us
Blog
Portal
IVF Center Registration
IVF Center Name*
Center Website
Has your IVF Center been known by a different name in the past?*
Yes
No
Previous Name
Address for Clinic*
Address line 2
City
State/Province
ZIP / Postal
Country
Will Lysis Buffer be sent to this address?*
Yes
No
Address for Labratory (this is where we will send Lysis Buffer)*
Address line 2
City
State/Province
ZIP / Postal
Country
Does your center have multiple addresses?*
Yes
No
Additional Addresses
Main Phone Number*
Physician NPI Number
Department Phone Extensions
Fax
Number of Physicians on Staff*
1
2
3
4
5
6
7
8
9
10
1. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
2. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
3. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
4. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
5. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
6. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
7. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
8. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
9. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
10. Physician Name*
Physician NPI Number
Physician Phone Number
Physician Email*
Number of Nurses/IVF or PGD Coordinators on Staff*
1
2
3
4
5
6
7
8
9
10
1. Nurse Name
Nurse Phone Number
Nurse Email
2. Nurse Name
Nurse Phone Number
Nurse Email
3. Nurse Name
Nurse Phone Number
Nurse Email
4. Nurse Name
Nurse Phone Number
Nurse Email
5. Nurse Name
Nurse Phone Number
Nurse Email
6. Nurse Name
Nurse Phone Number
Nurse Email
7. Nurse Name
Nurse Phone Number
Nurse Email
8. Nurse Name
Nurse Phone Number
Nurse Email
9. Nurse Name
Nurse Phone Number
Nurse Email
10. Nurse Name
Nurse Phone Number
Nurse Email
Administrative Staff
Administrative Staff Phone Number(s)
Administrative Staff Email(s)
Who would be the best person/people to contact for updates on mutual patients?
Laboratory Information
Lab Director
Lab Phone Number
Lab Director Email
Who would be the best person/people to contact for updates on mutual patients?
Does RGI need to provide an Embryologist to travel for biopsies?*
Yes
No
Number of Embryologists that perform biopsies
1
2
3
4
5
1. Embryologist Name
Embryologist Phone Number
Embryologist Email
2. Embryologist Name
Embryologist Phone Number
Embryologist Email
3. Embryologist Name
Embryologist Phone Number
Embryologist Email
4. Embryologist Name
Embryologist Phone Number
Embryologist Email
5. Embryologist Name
Embryologist Phone Number
Embryologist Email
Does your lab have a laser to perform trophectoderm biopsies?*
Yes
No
Do you require RGI to arrange courier pick-up for biopsy samples?*
Yes
No
Pick-up biopsies from which address?*
Clinic address
Labratory address
Other address
Address*
Address line 2
Country
City
State/Province
ZIP / Postal
Results Delivery Method
Email
Fax
Results Email(s)*
Results Fax Number(s)
Additional Notes
Please ensure Javascript is enabled for purposes of
website accessibility