New Patient Registration

New Patient Registration
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 *
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

Progyny Carrot
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 *
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 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? *
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) *

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? *
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 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
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? *
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)