We have posted several of our practice forms for patients' convenience. Many are available in both Word and PDF format. If you are interested in making an appointment please see our "New Appointments" page.

  General Forms  

1. Introduction to RCC Letter: Introduction RCC Letter  v4 (.pdf)
2. Patient Registration Form: Registration Form (.pdf format) ; Registration Form Digital v3
3. Medical Information Questionnaire that has questions for both the husband and the wife.  
    Digital Format (preferred): Medical History Form V6 (Word Digital format);
    PDF Format: Medical History Form v13
4. Patient portal (preferred secure method for information entry):
    https://secure.fertilitydr.com/patient/ or click on the icon below

 

Patient Portal


Enter information into the patient portal (highly preferred method - see : http://www.fertilitydr.com/new-appointments.html) or download the appropriate files, please print and fill-in all fields. FAX (801-878-8890) or mail the completed forms to our office in order for it to arrive at least 3 days prior to your scheduled initial consultation. A digital registration and history form is also available (preferred format) for electronic completion. The completed forms can be sent back electronically to info@FertilityDr.com and signed during the appointment.

If you have consulted with other physicians or practices regarding your infertility, please request that copies of your records be sent in advance. Specifically request any previously completed hormonal testing (such as Prolactin, TSH, day 3 FSH and day 3 estradiol, day 10 FSH, testosterone, DHEAS, fasting glucose, or fasting insulin levels), Clomiphene Citrate Challenge test (CCCT), a saline sonogram (hysterosonogram), hysterosalpingogram (HSG), laparoscopic or hysteroscopic surgery or semen analysis. Request that copies of the reports and actual films from any x-rays be sent for review. Records regarding any treatment such as clomiphene citrate, gonadotropin (FSH) injections, intrauterine insemination (IUI) or in vitro fertilization (IVF) should also be obtained.

Completing the registration form, questionnaire and obtaining all pertinent medical records in advance will allow our physicians to have access to all your records prior to your arrival. This will enable us to provide the best advice possible for your particular medical situation during your initial consultation. For financial information regarding the initial consult see: pricing

Patient Satisfaction Questionnaires

Your feedback is important to us. Please complete the questionnaire for your primary RCC physician by clicking on the link below.

If you have recently completed an initial consult with one of our physicians please complete the following:
1. Dr Keith L. Blauer: http://survey2.9gs.org/survey.php?code=v2qct7b
2. Dr. James S. Heiner: http://survey2.9gs.org/survey.php?code=d6kfq09

If you have recently completed an IVF cycle with one of our physicians please complete the following:
1. Dr Keith L. Blauer: http://survey2.9gs.org/survey.php?code=0g5ykhk
2. Dr. James S. Heiner: http://survey2.9gs.org/survey.php?code=sqaz8uc

  Forms for IVF Patients  

IVF Combined Information Forms and Consents for RCC: IVF Combined Consents V25.pdf

1. IVF Consent Form:1-IVF Consent v12.pdf
2. ICSI Consent Form: 2-ICSI Consent V8.pdf
3. Fresh Embryo Transfer Consent:  3- Fresh Embryo Transfer Embryo Number Consent v12.pdf
4. Embryo Cryopreservation Consent: 4-Embryo Cryopreservation (freezing) Consent v8.pdf
5. Cystic Fibrosis Testing: 5-Cystic Fibrosis Testing Consent v4.pdf
6. Self Administered Medicine Flow sheet: 6-Self Administered Medication Administration Flowsheet.pdf
7. IVF and Associated Procedures, Cost: 7-IVF and Associated Procedure Cost Information 2009 v7.pdf
8. IVF Payment Agreement: 8-IVF-Payment Agreement 2009 v7.pdf
9. Assisted Hatching Consent: 9-Assisted Hatching Consent v6.pdf
10. Lower Stimulation, Lower Cost IVF: Low Stim IVF Financial Policies v3.pdf

  Forms and Consent for Repeat IVF Patients  

Combined Updated Consents: Combined Update Consents v14.pdf

Subsequent Cycle No Change: Subsequent cycle consent.pdf
3. Fresh Embryo Transfer: 3 Fresh Embryo Transfer Embryo Number Consent v12.pdf
6. Self Administered Medicine Flow sheet: 6-Self Administered Medication Administration Flowsheet.pdf
8. IVF Payment Agreement: 8 IVF-Payment Agreement 2009 v7.pdf
9. Assisted Hatching Consent: 9-Assisted Hatching Consent v4.pdf


  Consent for Frozen Embryo Transfer Patients  

1. FET Combined Consents: FET Combined Consents V7.pdf
2. Frozen Embryo Transfer Consent: Frozen Embryo Transfer Consent - # to thaw and transfer (pdf) v9
3. FET Payment Agreement: FET Payment Agreement 2009 v2.pdf
4. FET Costs: FET Costs 2009 V2.pdf
5. Assisted Hatching Consent: 9-Assisted Hatching Consent v6.pdf

  Consent for Donor Egg Recipients  

1. Combined Recipient Consent Forms: Combined Recipient Consent Forms v10.pdf
2. Donor Egg (Anonymous) Consent Form: 1-Donor Egg (anonymous) Recipient Consent Form RCC v1
3. Donor Egg and FET Financial Policy 2008: 7- Donor Egg and FET Financial Policy2009 v6.pdf
4. Donor Egg IVF Payment Agreement 2008: 8-Donor Egg IVF Payment Agreement 2009 v2.pdf
5. In addition, forms for ICSI, Fresh Embryo number, embryo cryopreservation, and cystic fibrosis are used from the IVF Forms section above


  Egg Donor Forms  

1. Egg Donor Pre cycle Medical History Update: Egg Donor Pre-cycle Medical History Update v5 (pdf)
2. Self Administered Medicine Flow sheet: 6-Self Administered Medication Administration Flowsheet.pdf
3. Egg Donor Medical and Genetic History: Egg Donor Medical and Genetic History Questionnaire V9
4. Egg Donor Personal Information: DE-01F5-RCC Egg Donor Personal Information V3

  Donor Embryo History and Consent Forms  

1. Donor Embryo Irrevocable Consent: Donor Embryo Irrevocable Consent V3.pdf
2. Donor Embryo Combined Medical and Genetic History: Donor Embryo Combined Medical & Genetic Hx Digital V3.doc

  Miscellaneous Forms and Consents  

Forms- Instructions

After downloading the appropriate files, please print and fill-in all fields. A witness from Reproductive Care Center or a Notary public are required to verify the signature on some of the consent forms.  FAX (801-878-8890) or mail the completed forms to our office or review and bring them to your next office visit for discussion and signing.

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