Forms

We are making these patient forms available to you online to make it easier for you to access at your own convenience, before or after your fertility appointment, and to fill out as requested by our clinical staff.

New patient visit

• Female Patient History
• Male Patient History
• Insurance Information
• Request for Release of Medical Information
• Permission to Discuss PHI
• Zika Virus Information
• Zika Acknowledgment

IUI/IVF preparation

• In Vitro Fertilization (IVF) Patient Information
• Online Orientation Group Confidentiality Agreement

IUI consents

• Intrauterine Insemination (Donor)
• Intrauterine Insemination (Partner)

IVF consents

• In Vitro Fertilization (IVF) Treatment Plan Form
• Frozen Embryo Thaw Cycle and Transfer Consent
• Freezing of Embryos Consent
• Egg Freezing and Disposition of Frozen Eggs Consent

Third party reproduction consents/forms

• Consent to Use of Sperm from Known Donor with Risk Factors
• Surrogacy Procedure Agreement: Surrogate Consent
• Consent to Use of OVA from Known Donor with Risk Factors
• Agreement to Cryopreserve for Directed Donor Consent
• Consent to Donation of Embryos/Gametes
• Consent to Receive Donated Embryos/Oocytes
• Consent to Use Donated Embryo Cell or Tissue
• Consent to Use Reproductive Cell or Tissue from Exempt Donor 
• Recipient of Donor Oocyte Consent
• Donor Oocytes Consent
• Gestational Surrogacy Consent
• Intended Parents Transfer to Gestational Carrier Consent
• Clinic Male Donor Physical Exam
• Clinic Female Donor Physical Exam
• Third Party HIPPA Acknowledgement
• OFA Donor Acknowledgement of Risk Factors
• Sperm Donor Acknowledgement of Risk Factors

Other consents

• Discard Consent
• Informed Consent for Genetic Disease Carrier Screening-Female
• Informed Consent for Genetic Disease Carrier Screening-Male

Research

• Research Participation Consent

Policies

• Pre Payment Policy

Appointment instructions

• Blood Draw Instructions
• IUI Instructions
• Semen Analysis Instructions
• Andrology and Laboratory Test Requisition
• Sperm Cryopreservation

Contact us if you have any questions at (844) 661-9857