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Appointment Request
Please fill out the entire form and submit for an appointment request.
Name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Can this phone number receive texts?
*
YES
NO
Email
*
example@example.com
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Next
Reason for appointment
*
CPT #89310 - Semen Analysis: count and motility
CPT #89320 Semen Analysis Complete: count, motility, & morphology
Other
Are you a new or returning patient to CRBI?
*
NEW Patient
RETURN Patient
A doctors order is required for a semen analysis appointment. Who is your referring M.D.?
*
Please provide the Doctor who referred you to CRBI
Please upload a copy of your doctor's order
Browse Files
Drag and drop files here
Choose a file
If unable to upload form, please bring a copy with you to your appointment (this is required).
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of
Note: WE DO NOT PARTICIPATE WITH ANY INSURANCE COMPANIES.
How do you plan on paying the $160 semen analysis fee?
*
Credit Card (all credit card payments must be made through our online portal prior to your appointment)
Cash (please provide exact amount on day of appointment)
Check (made out to CRBI on day of appointment)
Have you filled out and submitted a Patient Registration Form (either online or by hand) to our office?
*
YES
NO
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Please provide a photocopy of your identification (If you are unable to upload at this time, please bring your ID to your appointment. This is required.)
Appointment
*
Notes
Please provide any notes including requests for an earlier appointments if they become available.
Appointment Date
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Month
-
Day
Year
Date
Appointment Time
Hour Minutes
AM
PM
AM/PM Option
Reminder Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
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