CRBI Appointment Request

Semen Analysis Appointment Request

Please fill out the entire form and submit for an appointment request. PLEASE NOTE: (CRBI does NOT provide a translator or use translation services. Please schedule an appointment when you are able to bring a translator, or your appointment will be cancelled.)
Patient Name*

First NameLast Name
Patient date of birth*

MonthDayYear
Date
Patient Phone Number*
Please enter a valid phone number.
Can this phone number receive texts?*

YESNO
Patient Email*
example@example.com
Partner's Name (patient name if single)*

First NameLast Name
Partner date of birth (patient DOB if single)*

MonthDayYear
Date

Are you a new or returning patient to CRBI?*

NEW PatientRETURNING Patient
Reason for appointment (IF CRYOPRESERVATION contact 317-817-1147 option 6-DO NOT SCHEDULE ONLINE)*

CPT #89322 - Semen Analysis Complete: Full DiagnosticCPT #89310 Semen Analysis: Post VasectomyOther
A physician's order is REQUIRED. Who is your referring M.D.?*
Please provide the Doctor who referred you to CRBI
Please upload a copy of your doctor's order.

If unable to upload form, please contact clyons@reproductiveindiana.com or text 317-817-1147.
Cancelof
Appointment*
Notes
Please provide any notes including requests for an earlier appointments if they become available.

Note: CRBI is Out-of-Network with ALL Insurance companies.
A Semen Analysis fee of $200.00 is required at least 1 day PRIOR to your appointment. Have you submitted your $200.00 payment?*

YESNO
Have you filled out and submitted a Patient Registration Form*

YESNO
Please provide a photocopy of your VALID identification (Please also remember to bring your VALID ID with you to your appointment. This is required.)
Appointment Date

MonthDayYear
Date
Appointment Time

Hour Minutes

AM/PM Option
Reminder Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Semen Analysis Appointment Request