New Patient Registration
If you are a MALE seeking Semen Analysis testing ONLY, please go back to our website and select the "SEMEN ANALYSIS" form, thank you!
PATIENT FIRST NAME - Patient Name ("Patient" 1) female in a heterosexual relationship 2) female treating in a female/female relationship and 3) the sperm source in a male/male relationship)
*
First name only
PATIENT MIDDLE NAME
Middle name or Initial
PATIENT LAST NAME
*
Full Legal last name
Patient DOB
*
-
Month
-
Day
Year
Date
Patient Gender
*
Female
Male
Other
Transgender
Patient/Couple
*
Female/male
Female single
Female/female
Male single
Male/male
Other
Marital status
*
Married
Single (donor sperm/egg)
Domestic partnership
Other
Patient Race
*
American Indian/Alaska Native
Asian
Black/African American
More than one race
Native Hawaiian
Pacific Islander
Unreported/Refused to report
White
Patient ethnicity
*
Hispanic/Latino
Non-Hispanic
Unreported/Refused to report
Preferred Language
*
English
Spanish
French
German
Somali
ASL
Other
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
Preferred method of communication
*
Email
Phone - Mobile
Phone - Work
Phone - Home
Other
Patient height and weight
*
BMI Criteria
Less than 40 for IUI/Inseminations & donor egg IVF
Less than 35 for IVF using own eggs
Insurance Name
*
Insurance Group#
*
Insurance ID#
*
Check here if you have Progyny or Carrot Insurance
Progyny
Carrot
Progyny ID#
*
If Insurance is provided through your employer, who is your employer?
Employer name
Preferred Pharmacy
*
Pharmacy Name
Pharmacy Address
City
State / Province
Postal / Zip Code
Preferred Pharmacy Phone
-
Area Code
Phone Number
Partner FIRST Name
*
First name only
Partner MIDDLE Name
Partner LEGAL LAST Name
*
Partner DOB
*
-
Month
-
Day
Year
Date
Partner Gender
*
Female
Male
Other
Transgender
Partner Race
*
American Indian/Alaska Native
Asian
Black/African American
More than one race
Native Hawaiian
Pacific Islander
Unreported/Refused to report
White
Partner ethnicity
*
Hispanic/Latino
Non-Hispanic
Unreported/Refused to report
Preferred Language
*
English
Spanish
French
German
Somali
ASL
Other
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
Insurance Name
*
Insurance Group#
*
Insurance ID#
*
If Insurance is provided through your employer, who is your employer?
Employer Name
How did you find out about RMIA?
*
Google
Internet search
Magazine/Newspaper
Blog
Ob/Gyn
Primary MD
Television
Radio
Friend
Current/Previous patient
Drove by building
Insurance
RMIA employee
Other
What is your Ob/Gyn, physician's name?
*
If you currently do NOT have an Ob/Gyn, we will require you establish care with one prior to treatment.
Ob/Gyn Clinic name/address
*
If referred by a current/former patient, who was it?
Are you seeking treatment or 2nd opinion?
*
Treatment
2nd Opinion
Have you (partner too) viewed our IVF seminar video?
*
No
Yes
Unsure
Have you received our IVF informational packet?
*
No
Yes
Unsure
Latex allergy?
*
None
Patient only
Partner only
Both
Other allergy?
*
None
Patient only
Partner only
Both
Do you/partner need to lie down for blood draws?
*
No
Yes
Unsure
Cigarette smoker?
*
None
Patient only
Partner only
Both
If Patient is female, first day of most recent period
*
Have you taken any fertility drugs (including clomid) or had an insemination since your last period?
*
No
Yes
Unsure
Do you plan on doing another cycle with your current physician?
*
No
Yes
Unsure
What have you been told is the reason(s) for your infertility (check all that apply)
*
Tubal Factor (previous ectopic pregnancy, tubal ligation, blocked fallopian tubes)
Menstrual Disorder (irregular cycles, no periods)
Recurrent Pregnancy Loss
Premature Ovarian Failure
Male Factor
Male Factor - have frozen sperm available
Male Factor - no sperm, need surgery to extract
No Sperm Source
Unexplained (testing has not indicated a cause)
Unknown (no testing has been done)
Have you ever been pregnant?
*
No
Yes
How many live birth(s)?
*
Delivery
*
Vaginal delivery
C-section
How many miscarriage/abortion(s)?
*
What infertility testing/evaluation have you and your partner had done(check all that apply)
*
Semen Analysis
Male has been evaluated by a urologist
Hysterosalpingogram (HSG) Tubal dye test
Female has had hormone blood testing
Post Coital test
Laparoscopy
Hysteroscopy
None
What type of infertility treatment have you already undergone?(check all that apply) -InvoCell is no longer offered at RMIA
*
Clomid cycles
Intrauterine Insemination (IUI)
Ovarian stimulation cycles with injectable medications (Gonal-F® or Follistim®)
In Vitro Fertilization (IVF)
None
Are you considering other Infertility centers?
*
No
Yes
Are you interested in testing to see if you/partner is a carrier for genetic disorders/diseases?
*
No
Yes
Unsure
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
What type of infertility treatment are you seeking at RMIA? *
*
Ovarian stimulation cycles with IUI (monitoring must be done at RMIA)
IVF with Own Eggs
IVF with Donor Eggs
Family Balancing
IVF with Limited Fertilization of Eggs
Egg Freezing
Egg Freezing/IVF - URGENT due to upcoming cancer treatment
FET with own embryos frozen at RMIA & stored at RTL
FET with Donated embryos frozen at RMIA & stored at RTL
Ovarian Reserve Assessment
IVF with donor sperm
Ovarian stimulation with IUI using donor sperm
If you chose "Other" as treatment option, please explain:
*
Is your egg/sperm donor KNOWN or ANONYMOUS (egg/sperm bank)?
If IVF is the treatment option you are seeking, when do you plan to undergo treatment?
*
ASAP
1-3 months
3-6 months
6-12 months
Are you interested in PGT (preimplantation genetic testing) of embryos in an 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
Michelle Valentine, CNP
No Preference
Valid Photo Identification and Insurance card(s)
If you receive an error in attempting to upload your images, you will be provided with a link after this submission to send them through an alternate link.
Upload/take photo of Patient VALID identification (license, passport) PLEASE MAKE SURE ALL TEXT IS LEGIBLE ON IMAGES
Upload/take photo of FRONT of insurance card PLEASE MAKE SURE ALL TEXT IS LEGIBLE ON IMAGES
Upload/take photo of BACK of insurance card PLEASE MAKE SURE ALL TEXT IS LEGIBLE ON IMAGES
Upload/take photo of PARTNER'S VALID identification (license, passport) PLEASE MAKE SURE ALL TEXT IS LEGIBLE ON IMAGES
Upload/take photo of FRONT of insurance card PLEASE MAKE SURE ALL TEXT IS LEGIBLE ON IMAGES
Upload/take photo of BACK of insurance card PLEASE MAKE SURE ALL TEXT IS LEGIBLE ON IMAGES
Submit
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