CLIENT INTAKE FORM Please complete intake form below. Full Name *Partner's Name (Not Required)Phone Number *Email Address *Date of Birth *Street Address *Apartment, Suite, Etc.City *State *ZIP / Postal Code *Cycle Type *IVF PMIVF Twice A DayFertility Preservation PMFertility Preservation Twice A DayStimulation Injection CoachingFET AMFET PMIntramuscular Injection CoachingHCG/Ovidrel Trigger ShotFertility Clinic *Baseline Date *Preferred Injection Time *HourMinuteAMPMAdditional Details (If Applicable)Terms and Conditions *This In-Home Nursing Service Contract is entered between you, the Client, and Sophie Sharabi, R.N. with Gentle Touch Fertility Services (the Service Provider). The Client and the Service Provider shall be collectively known herein as the Parties. WHEREAS, the purpose of this contract is to set out the terms of services to be provided to by Service Provider generally known as Gentle Touch Fertility Services. In consideration of the mutual promises and other valuable consideration exchanged, the Parties hereby agree and contract as follows: Your Service Provider understands that any and all private information obtained about the Client, Client’s family, or relatives during the course of employment, including but not limited to medical, financial, legal, career and assets are strictly confidential and may not be disclosed to any third party for any reason. The obligations of your Service Provider under this clause survive termination of this contract. 1. LICENSING. The Service Provider warrants that each Service Provider representative is licensed in the state of California to provide the services mentioned in this contract. Further, any employee or representative of the Service Provider performing services under this contract is licensed in the state of California as a Registered Nurse, Licensed Vocational Nurse or Certified Medical Assistant, and is current on all training and certifications. 2. DESCRIPTION OF SERVICES. The Service Provider shall have the power to administer the prescribed subcutaneous and intramuscular medications as ordered by the Client’s physician. 3. INTERFERENCE. The Client understands that she is hiring the Service Provider to do all activities surrounding medication preparation and administration. Any interference by the Client around these activities will void this contract. This statement is meant to protect the client from any clinical errors that can arise if numerous people are a part of the injection process. 4. PAYMENT SCHEDULE. Payment for the services will be due every 2 weeks. The Client will be invoiced for payment through Stripe, and payments can be made online using any major credit or debit card. 5. CANCELLATION POLICY. If the Client decides to cancel her scheduled appointment, the Client must provide a 12 hour notice to the Service Provider. If less than 12 hours advance notice is provided, 50% of the fee will be charged to the Client. The Client will not be charged the cancellation fee if the cancellation is due to a pregnancy test result or doctors cycle orders. 6. DETAILS OF INSURANCE COVERAGE. The Client understands that payment to Gentle Touch Fertility Services must be paid on the due date. If the client wishes to contact their insurance provider, a sale receipt can be provided for reimbursement. 7. ATTORNEYS FEES. In the event of any breach of this Contract, the party responsible for the breach agrees to pay reasonable attorney fees and costs incurred by the other party in the enforcement of this contract or suit for recovery of damages. The prevailing party in any suit instituted arising out of this contract will be entitled to receive reasonable attorneys fees and costs incurred in such suit. CHECK BOX ABOVE TO ACCEPT TERMS & CONDITIONSSUBMIT INTAKE FORM