Fertility Preservation Form "*" indicates required fields Accept Terms and Conditions:*Please make sure you have all of the following available before progressing to the next step. I have read and understand the terms and conditions. I have 3 months bank statements ready I have 3 months payslips ready I have 3 months credit card statements ready I have a rent/bond statement ready I have my financial details spreadsheet ready I have my signed agreement letter ready I have the signed rabbi’s consent form ready 3 Months Bank Statements* Drop files here or Select files Max. file size: 256 MB, Max. files: 3. 3 Months Credit Card Statements* Drop files here or Select files Max. file size: 256 MB, Max. files: 3. Hidden3 Month Pay Slips (old)Accepted file types: pdf, pdf, xls, xlsx, doc, docx, Max. file size: 256 MB.3 Month Pay Slips* Drop files here or Select files Max. file size: 10 MB. 3 Month Bond/Rent Statement* Drop files here or Select files Max. file size: 10 MB, Max. files: 3. Financial Spreadsheet*Max. file size: 256 MB.Agreement Letter*Max. file size: 10 MB.Rabbi's Consent Form*Max. file size: 10 MB.Income Status* I earn an income I do not earn an income Your Name* First Last Your Hebrew Name* Your Mother's Hebrew Name* Your Father's Hebrew Name* Your Date of Birth* DD slash MM slash YYYY Cell Phone Number*Email Address* Were you born Jewish?* Yes No Where were you converted (which Rabbinical court)* When were you converted?* MM slash DD slash YYYY Do you keep Shabbas and Kashrut?* Yes No Which shul do you attend?* Your Rabbi's Name* RabbiRabbiRabbi Dr Prefix Last Is your rabbi aware you are undergoing a fertility preservation process?* Yes No Fertility Doctor's Name* First Last Fertility Clinic* Fertility Doctor's Phone*Fertility Doctor's Email* Medical Aid* I have medical aid. I do not have medical aid. Medical Aid Provider* Medical Aid Plan* Medical Aid Number* Have you done Oocyte Freezing before?* Yes No When did you do this?* MM slash DD slash YYYY Was this treatment at a clinic different to your current clinic?* Yes No Current Fertility Doctor's Name* First Last Fertility Clinic* What was the approximate cost of past procedures?*Please disclose any additional information which may be helpful or important to us addressing your applicaiton:Declaration of Accuracy* I declare that the information provided is accurate and complete to the best of my knowledge Ohel Sarala is an initiative in which couples struggling with infertility & single woman struggling to get married daven for each other. Please indicate if you would you like to be part of this initiative. Complete confidentiality is assured as only hebrew names are shared.* Yes No
