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We have posted several of our practice forms for patients' convenience. If you are interested in making an appointment please see our "New Appointments" page.
1. Introduction to RCC Letter:
Introduction RCC Letter
v4 (.pdf)
2. Patient portal (secure method for
entering your medical and demographic information and for Web correspondence with the staff):
https://secure.fertilitydr.com/patient/
or click on the icon below
Patient Portal
Enter information into the patient portal (see : http://www.fertilitydr.com/new-appointments.html), please fill-in all fields. We require that you complete the data entry at least 3 days prior to your scheduled initial consultation otherwise we recommend you reschedule.
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 patient portal 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
1. Frozen Embryo Transfer Consent:
Frozen Embryo Transfer Consent - # to thaw and transfer (pdf) v9
2. Assisted Hatching
Consent: 9-Assisted Hatching Consent v6.pdf
1. Donor Egg (Anonymous) Consent Form:
1-Donor Egg (anonymous) Recipient Consent Form RCC v1
2. In addition, forms for ICSI, Fresh Embryo number, embryo cryopreservation, and cystic fibrosis are used from the IVF Forms section above
1. Egg Donor Pre cycle Medical History Update:
Egg Donor Pre-cycle Medical History Update
v5 (pdf)
2. Egg Donor Medical and Genetic History:
Egg Donor Medical and Genetic History
Questionnaire V9
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
1. Medical Records Release Form: Adobe PDF File ; Word Digital File
2. Letrozole for Ovulation Induction:
Letrozole (Femara) Use for Ovulation Induction
v3 (Word);
Letrozole (Femara) Use for Ovulation Induction (PDF)
v3
3. Intrauterine insemination (Husband):
Insemination IUI Consent v3 (pdf);
Outside Insemination IUI Consent (pdf);
4. Surrogacy
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Gestational Surrogate Medical History Form Digital v7;
A witness from Reproductive Care Center or a Notary public is 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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