Please have valid identification card(s) and insurance card(s) available for upload
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile phone
*
-
Area Code
Phone Number
Work phone
-
Area Code
Phone Number
Home phone (if different than above)
-
Area Code
Phone Number
Email
*
example@example.com
Patient height and weight
*
Patient's Insurance Name
*
Insurance Group#
*
Insurance ID#
*
Partner name
First Name
Last Name
Partner DOB
-
Month
-
Day
Year
Date
Partner address (if different than above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Partner mobile phone
-
Area Code
Phone Number
Partner work phone
-
Area Code
Phone Number
Partner email
example@example.com
Partner's Insurance Name
Insurance Group#
Insurance ID#
Do you or your partner have any flu-like symptoms (cough, fever, shortness of breath)?
*
No
Yes
Have you been in close contact with someone who has been diagnosed with COVID-19 within the last 14 days?
*
No
Yes
Have you been tested for COVID-19 and awaiting results?
*
No
Yes
Have you been requested to self-quarantine?
*
No
Yes
Have you traveled to an area affected by the Ebola virus in the last 21 days?
*
No
Yes
Have you traveled to an area affected by the Zika virus in the last 8 weeks (6 months for men)?
*
No
Yes
Do you have plans to travel to a Zika/Ebola affected area in the next 6 months?
*
No
Yes
Ob/Gyn name
*
Ob/Gyn Clinic name/address
*
What type of treatment are you seeking?
*
IUI - Inseminations
IVF - Fresh IVF
FET - Frozen embryo transfer
OTHER
If you chose "Other" as the treatment option you are seeking, please explain:
Are you interested in PGT (preimplantation genetic testing) of embryos, either existing embryos or testing within a new IVF cycle? (additional costs would apply, please contact business office for more information).
*
No
Yes
Unsure
RMIA Provider preference?
*
Dr. Phoebe Leonard
Dr. Jani Jensen
Dr. Jacques Stassart
Dr. Tana Kim
Dr. Tana Kim
Michelle Valentine, CNP
No Preference
Have you had treatment elsewhere?
*
No
Yes
Have you achieved a spontaneous pregnancy or pregnancy loss since last seen at RMIA? (A pregnancy we may not know of).
*
No
Yes
Have you had a delivery since you were last seen at RMIA?
*
No
Yes
At how many weeks did you deliver? (i.e. 39-40 weeks is full term)
*
Delivery
*
Vaginal delivery
C-section delivery (we will need operative report)
Other
Are you currently breastfeeding?
*
No
Yes
When do you plan to discontinue breastfeeding? Treatment cannot begin until breastfeeding has completely ceased due to response to medications and affect of medications on infant.
*
Any health changes since you were last seen at RMIA?
*
No
Yes
Please explain health changes
Upload/take photo of PATIENT'S VALID identification (license, passport)
Upload/take photo of FRONT of insurance card
Upload/take photo of BACK of insurance card
Upload/take photo of PARTNER'S VALID identification (license, passport)
Upload/take photo of FRONT of insurance card
Upload/take photo of BACK of insurance card
Click HERE to submit, you will be routed to complete TWO more segments to include HIPAA, COVID-19 consent and Medical record release
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