Connect with a Restorative Reproductive Medicine (RRM) Clinician or Healthcare Provider

 
Restorative Reproductive Medicine Referral

If you’re seeking support with fertility (male or female), hormonal health, menstrual cycle concerns, or women’s health issues, our referral team is here to help. By completing the form below, you’ll be connected with a trusted clinician, educator, or allied healthcare provider trained in Restorative Reproductive Medicine (RRM).

Your request will be reviewed by our referral coordinator, who will match you with a qualified RRM clinician, practitioner, or clinic based on your location, preferences, and care needs. Virtual and in-person consultations may be available depending on your region.

If you are a healthcare professional or IIRRM member looking to refer a patient you can share this link with your patient or send us an email.

🔒Your information is strictly confidential. It will be stored securely, never sold, and only used with your permission for care coordination and optional internal research (with notification). We may follow up by email or phone if you consent below. Most requests receive a response within 3–5 business days.

Name
 
What type of RRM care are you looking for?
 
RRM services can often be offered via telehealth, which allows you to meet virtually and securely with your care team from your home or any private location often over video-conferencing technology. The team or provider will help coordinate in-person services needed as part of your evaluation & treatment with local providers such as bloodwork, semen analysis, ultrasound imaging, etc.
 

Patient Information

Previous Diagnoses (Check all that apply):
 
 
How did you hear about IIRRM's patient referral service?
Use this space to provide any further information or questions you would like to share.
 
Consent
Consent to Collect, Use, and Store Personal Information

By submitting this form, you acknowledge and consent to the collection, use, and limited storage of your personal information for the sole purpose of facilitating a referral to a qualified restorative reproductive medicine (RRM) clinician, educator, or allied healthcare provider.

Your information will be handled as follows:

Data Protection Compliance:
Your personal data will be processed and stored in accordance with applicable UK data protection legislation, including the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.

Limited Access:
Your information will only be accessed by designated referral personnel (e.g., Patient Liaison) solely for the purpose of identifying and providing suitable referral options.

No Third-Party Sharing:
Your information will not be shared with any third parties outside of the referral coordination process without your explicit consent.

Data Retention:
Your personal data will be retained for a maximum period of six (6) months to facilitate appropriate follow-up. After this period, all identifiable information will be securely and permanently deleted.

Legal Capacity:
By submitting this form, you confirm that you are of legal age of consent in your jurisdiction and capable of making decisions regarding your own healthcare.

Use of De-Identified Data:
If selected, the International Institute for Restorative Reproductive Medicine (IIRRM) may use de-identified and aggregated information (e.g., referral region, type of request) for quality improvement, reporting on access to care, and identifying unmet needs. No personally identifiable or health information will be disclosed or published. You may opt in or out above.

Follow-Up Contact:
If selected, you consent to being contacted for follow-up purposes regarding your referral and ongoing care.

You have the right to request the deletion of your personal information at any time by contacting us. A copy of your completed form will be emailed to you upon submission.
Clear Signature