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Patient Story
Patient Story
Name
*
First
Last
Phone
*
Email
*
Have you been seen as a patient at Kentucky Fertility Institute?
*
Yes
No
Please give your story a title
*
Your Story
*
Please share 2-3 paragraphs about your story with us.
If you have a photo you'd be willing to share with us, please upload it. We would love a family photo.
With your permission, we will use this photo on our social media sites {facebook & instagram}, our website www.kentuckyfertility.com and our affiliates social sites and websites *Please note, no ultrasound or pregnancy test pictures. We want to be sensitive to the families still trying to conceive.*
I agree to allow Kentucky Fertility Institute and its affiliates to publicly share my Patient Story and Photo.
*
Yes
No
Please note your contact information will not be displayed. Kentucky Fertility Institute only needs your email/phone in case we need to reach you.
I have read & agree to the General Consent and Release form (link below).
*
Agree
Click here
to read our General Consent & Release.