New Fertility Patient Information
Your new patient registration process can go much smoother when you perform the following steps.
Please print and complete the following information prior to your first visit. We do ask that you check in 20 minutes prior to your appointment in order for us to complete the registration process.
STEP 1 (print and complete all)
Please PRINT and COMPLETE ALL of the following forms You will be expected to bring these completed forms & pertinent past medical records to your first appointment.
- New Patient Appointment Checklist
- Female History
- Male History
- Patient Demographics
- Additional Required Information
- Referring Physician Form
- Joint Notice of Privacy Practices (read and print for your records)
- HIPAA Authorization Form
- Email consent
- Patient Advisory Council Form
Please complete the form below. We cannot bill your insurance unless both you and your partner sign this form. Due to recently established HIPAA requirements, a medical practice must have the signed consent of every person receiving medical treatment allowing the practice to bill their insurance and to release medical information related to medical claims.
Please be sure that both partners have signed this form and given to our office staff. Without it, we are unable to bill your insurance and must look to you to be responsible for payment. Thank you for your cooperation.
If you need to send a medical release to another clinic / facility.
For your review: