RETURNING PATIENT FORM

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 *
BMI Criteria

Less than 40 for IUI/Inseminations

Less than 37 for donor egg IVF/Frozen embryo transfers

Less than 35 for IVF using own eggs
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
MUST BE DIFFERENT THAN PATIENT EMAIL ABOVE
Partner's Insurance Name
Insurance Group#
Insurance ID#
Do you or your partner have any flu-like symptoms (cough, fever, shortness of breath)? *
Have you been in close contact with someone who has been diagnosed with COVID-19 within the last 14 days? *
Have you been tested for COVID-19 and awaiting results? *
Have you been requested to self-quarantine? *
Have you traveled to an area affected by the Ebola virus in the last 21 days? *
Have you traveled to an area affected by the Zika virus in the last 8 weeks (6 months for men)? *
Do you have plans to travel to a Zika/Ebola affected area in the next 6 months? *
Ob/Gyn name *
Ob/Gyn Clinic name/address *
What type of treatment are you seeking? *
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). *
RMIA Provider preference? *
Have you had treatment elsewhere? *
Have you achieved a spontaneous pregnancy or pregnancy loss since last seen at RMIA? (A pregnancy we may not know of). *
Outcome of spontaneous pregnancy (miscarriage, ectopic, live birth...)
If live birth, vaginal or C-section delivery?
Have you had a delivery since you were last seen at RMIA? *
At how many weeks did you deliver? (i.e. 39-40 weeks is full term) *
Delivery *
Are you currently breastfeeding? *
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? *
Please explain health changes
Any previous contraindications or negative side effects while being on the birth control pill? *
If yes, what were your side effects/reason you should l not take the pill?
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
Should be Empty:

Please have valid identification card(s) and insurance card(s) available for upload