New Patient Registration

New Fertility Patient Registration

On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

New Patient Forms

Please complete all forms prior to your appointment and either bring with you or fax to

817-348-8264

 

New Patient Data Form

New Patient Questionnaire

Financial Agreement

HIPAA Forms

Cystic Fibrosis Policy Form

Medical Records Release Form, complete, and fax the form to physicians who have previously treated you. These records will be helpful to us. Please send one form to each prior physician.

Credit Card Form Complete and fax this form to 817-348-8264 if you need to utilize your credit card for any charges.

Andrology Lab Consents

 

Andrology Requisition Form Please have a referring physician complete this form before making an appointment with the andrology lab.

 

Sperm Storage Consents  Complete this form, which must be signed by both the patient and partner, and bring to your appointment.

 

Sperm Cryopreservation Consents Complete this form, which must be signed by both the patient and partner, and bring to your appointment.

 

Technical Note:
PC Users
Our online form uses Adobe Acrobat Reader http://get.adobe.com/reader/ 9 or greater plug-in to conveniently submit the form from home or work. Please download the free plug-in from Adobe's web site if it is not already installed on your system. It is important that you have at least version 9 of the plug-in to successfully use our online form.


Mac Users
You must open and submit the form in a Safari Browser with the latest Mac operating system. It is also important to have the latest version of Adobe Acrobat Reader on your computer. In order to submit your form to our office correctly, please download the free plug-in from Adobe's web site. http://www.adobe.com/support/downloads/product.jsp?platform=macintosh&product=10