RETURNING PATIENT FORM

Patient Name*

First NameLast Name

Patient DOB*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile phone*

Area CodePhone Number

Work phone

Area CodePhone Number

Home phone (if different than above)

Area CodePhone Number

Email*

example@example.com

Patient height and weight*

BMI Criteria

Less than 40 for IUI/Inseminations, Donor Egg IVF, Frozen Embryo Transfers

Less than 37 for IVF using own eggs

Patient's Insurance Name*

Insurance Group#*

Insurance ID#*

Partner name

First NameLast Name

Partner DOB

Date

Partner address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Partner mobile phone

Area CodePhone Number

Partner work phone

Area CodePhone 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?*

As of July 1st 2024, Dr. Stassart has retired.

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?*

List of current medications*

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

We hope that you achieved success in your previous treatment with us, if you did, this is a friendly reminder that we have a “No Children in Clinic Policy”. Please have appropriate child care for all in office visits. Thank you

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