Medical Evaluation Form

Your patient(s) is/are applying for a financial grant from Fertility Friends Foundation (FFF). 

In order to complete their Application, they need their physician to fill out this Medical Evaluation Form 

Once completed, please submit it to FFF directly by clicking  the button at the end of the form. 

Our medical committee, composed of fertility physicians, will review this Medical Evaluation.

If you have any question about the Medical Evaluation and/or Fertility Friends Foundation, please visit www.fertilityfriendsfoundation.com or email Executive Director, Isabelle Lefebvre-Vary:  isabelle.vary@fertilityfriendsfoundation.com

Privacy and Consent Notice

Fertility Friends Foundation (FFF) is committed to protecting the confidentiality and security of patient information. All personal and medical information collected through this Medical Evaluation is handled in accordance with applicable Canadian privacy laws, including PHIPA and PIPEDA, and in line with our Privacy Policy.

Please note that this Medical Evaluation is initiated by your patient(s) as part of their grant application, and submission of this form implies their consent to share relevant medical information with FFF for the purpose of application review.

If you have any questions or require additional documentation regarding patient consent, you may request that your patient complete the Authorization for Release of Medical Information via FFF Medical Evaluation, available on our grant application page: www.fertilityfriendsfoundation/apply-for-grant.