New Patient Registration

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*

MonthDay Year
Date
Patient Gender*
Patient/Couple*
Marital status*
Patient Race*
Patient ethnicity*
Preferred Language*
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*
Patient height and weight*
BMI Criteria

Less than 40 for IUI/Inseminations

Less than 37 for 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

ProgynyCarrot
Progyny ID#
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*

MonthDay Year
Date
Partner Gender*
Partner Race*
Partner ethnicity*
Preferred Language*
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#*
How did you find out about RMIA?*
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? *
Have you (partner too) viewed our IVF seminar video?*
Have you received our IVF informational packet?*
Latex allergy?*
Other allergy?*
Do you/partner need to lie down for blood draws?*
Cigarette smoker?*
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?*
Do you plan on doing another cycle with your current physician?*
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 LossPremature Ovarian FailureMale FactorMale Factor - have frozen sperm availableMale Factor - no sperm, need surgery to extractNo Sperm SourceUnexplained (testing has not indicated a cause)Unknown (no testing has been done)
Have you ever been pregnant?*
How many live birth(s)?*
Delivery*

Vaginal deliveryC-section
How many miscarriage/abortion(s)?*
What infertility testing/evaluation have you and your partner had done(check all that apply)*

Semen AnalysisMale has been evaluated by a urologistHysterosalpingogram (HSG) Tubal dye testFemale has had hormone blood testingPost Coital testLaparoscopyHysteroscopyNone
What type of infertility treatment have you already undergone?(check all that apply) -InvoCell is no longer offered at RMIA*

Clomid cyclesIntrauterine Insemination (IUI)Ovarian stimulation cycles with injectable medications (Gonal-F® or Follistim®)In Vitro Fertilization (IVF)None
Are you considering other Infertility centers?*
Are you interested in testing to see if you/partner is a carrier for genetic disorders/diseases?*
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?*
What type of infertility treatment are you seeking at RMIA? **

Ovarian stimulation cycles with IUI (monitoring must be done at RMIA)IVF with Own EggsIVF with Donor EggsFamily BalancingIVF with Limited Fertilization of EggsEgg FreezingEgg Freezing/IVF - URGENT due to upcoming cancer treatmentFET with own embryos frozen at RMIA & stored at RTLFET with Donated embryos frozen at RMIA & stored at RTLOvarian Reserve Assessment
If you chose "Other" as treatment option, please explain: *
If IVF is the treatment option you are seeking, when do you plan to undergo treatment?*
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). *
RMIA Provider preference?*
Dr. Jacques Stassart is no longer taking new patients
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
Should be Empty:

New Patient Registration

Valid Photo Identification and Insurance card(s)