Forms

You can shorten your office visit time by filling out forms in advance.

1. New Patient Letter
2. Patient registration form Both female and male must complete a registration form
3. New patient history form Both female and male must complete a registration form
4. Consent for infertility services
5. Authorization form for use and/or disclosure of protected health information
6. Designating others involved in your care
7. Pre-Authorized payment form
8. Acknowledgement and authorization payment policy

FORMS RELATED TO IN VITRO FERTILIZATION

1. IVF Global Consent Form - .Both female and male must complete a form
2. Acceptance of Cryopreserved Specimens from Another Facility ---- this form MUST be notarized or signature must be witnessed by Fertility Center Staff [pdf format]
3. Transfer of Cryopreserved Specimen to Another Facitlity---- this form MUST be notarized or signature must be witnessed by Fertility Center Staff [pdf format]
4. Transfer of Cryopreserved Specimen to Patient's Care---- this form MUST be notarized or signature must be witnessed by Fertility Center Staff [pdf format]
5. Requirements for Acceptance or Transfer of Cyropreserved Specimens [pdf format]
6. Sperm Cryopreservation and Storage Agreement [pdf format]
7. Physician's Request for Sperm Banking. [pdf format]
8. Frozen Embryo Disposition Form---- this form MUST be notarized or signature must be witnessed by Fertility Center Staff [pdf format]
9. Frozen Sperm Disposition Form ---- this form MUST be notarized or signature must be witnessed by Fertility Center Staff [pdf format]