Pilot Programme Form

1
Email* This field is required.(No spam or marketing emails, a dedicated direct line concierge will reach out)
example@example.com
Email Verified
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2
Have you previously undergone any fertility treatment?
Yes
No
Curious about your options
3
How many rounds have you done?
4
How much have you spent on treatment so far?* This field is required.
Please Select
Please Select
Under $25000
$25000 - $35000
$35000 - $50000
$50000 - $75000
>$75000
Not Applicable
5
How much coverage do you have from your employer/ insurance?* This field is required.
Please Select
Please Select
Not Applicable
Under $25000
$25000 - $35000
$35000 - $50000
$50000 - $75000
>$75000
6
Have you considered treatment internationally?* This field is required.
Yes
No
7
What is most appealing about international treatment?* This field is required.
Price
Experience
Standards
Success rates
Donor treatments (Price)
Donor treatments (Options of donor)
Not Applicable
8
What is least appealing about international treatment?* This field is required.
Organising the treatment
Finding reliable clinic
The cost of travel
The uncertainty of quality
Organising the travel (duration of stay)
Not Applicable
9
Which of the following countries would you consider for treatment* This field is required.Select all that are of interest
Mexico
Caribbean
Spain
Greece
Portugal
United Kingdom
Czech Republic
Canada/USA
Iceland
Not Applicable
10
Would any of the following services from Antares Health's Pilot Programme interest you? (The pilot programme offers you $300 credit for feedback, and upto $750 for feedback & reviews)* This field is required.
Clinic-patient match (based on patient's needs, criteria & budgets)
Treatment at your chosen top international clinic
Hybrid care: International treatment with local pre-treatment preparation
Online medication purchase
Hand held experience with premium virtual concierge (free for the pilot)
Support on navigating international regulation and laws
Flexible travel arrangement support
Accomoodation booking discounts
Treatment abroad (from 1 - 6 days overseas, based on treatment)
Donor related services
N/A
11
Please select your preference if you would like information and exclusive assistance through Antares Health* This field is required.
I want to join the pilot
Not interest
I would like more information
12
Please share any questions you have for us?We will get back in 48 hours if you have left your email
13
Name
First Name
Last Name
14
Lastly, where are you based? (City, Country)* This field is required.
15
How long have you been trying to conceive?* This field is required.(With or without treatment)
Please Select
Please Select
Less than 1 year
Past 2-3 years
3-4 years
More than 4 years
16
How soon would you like to start?* This field is required.
Please Select
Please Select
Immediately
Next 3 months
3-6 months
6-12 months
Just browsing options
17
Do you or your partner have any special needs?* This field is required.(This includes any medical conditions/past history of cancer care)
18
Please share a brief history of your past treatments and when the last round of treatment ended.* This field is required.
19
Do you have any specific needs you're aware of that we should consider? * This field is required.
Please Select
Please Select
Donor - Sperm
Donor - Egg
Donor - Embryo
Surrogacy
Genetic Testing
Other
N/A
20
Please verify that you are human* This field is required.By completing this step, you are consenting to our teams using your data to further support your request.
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