New Patient Pre-Registration Form
Atlantic Reproductive Medicine will be calling you from (919) 248-8777 to schedule your appointment.Please add this phone number to your contacts so that you will recognize the call. We look forward to scheduling your first appointment!
Patient Information
Patient Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number To Reach You:
*
Please enter a valid phone number.
Best time to call you to schedule your appointment:
Morning
Afternoon
Your Email Address:
*
example@example.com
Do you have an OB/GYN?
*
Yes
No
Did your OB/GYN refer you?
*
Yes
No
Please provide the name of your provider and OB/GYN practice .
*
Do you have previous fertility treatment records?
*
Yes
No
Please fill out our Authorization to Release Medical Records by clicking here.
Do you have a partner?
*
Yes
No
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Your Partner Information:
Partner's Name:
*
Last Name
Partner Date of Birth:
*
-
Month
-
Day
Year
Date
Is your partner's address different than yours?
*
Yes
No
Partner's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Partner's Phone Number:
*
Please enter a valid phone number.
Partner's Email Address:
*
example@example.com
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What fertility treatment are you seeking?
*
Infertility consultation (diagnosis & treatment)
Fertility Testing
Fertility Preservation (Egg & Sperm Freezing)
Recurrent Pregnancy Loss
IVF (In Vitro Fertilization)
IUI (Intrauterine insemination)
INVOcell
Genetic Testing
LGBTQ+ Family Building
Single Parent Family Building
Male Fertility
Other
Is this for a vasectomy consult?
*
Yes
No
Do you have insurance?
*
Yes
No
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Your Insurance Information:
Company:
*
Group Number:
*
Subscriber ID:
*
Subscriber Name:
*
Subscriber Date of Birth:
*
-
Month
-
Day
Year
Date
Does your partner have insurance different than yours?
*
Yes
No
Partner's Insurance Information:
Partner's Insurance Company:
*
Partner's Insurance Group Number:
*
Partner's Insurance Subscriber Name:
*
Partner's Insurance Subscriber ID:
*
Partner's Insurance Subscriber Date of Birth:
*
-
Month
-
Day
Year
Date
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How did you hear about Atlantic Reproductive Medicine?
*
Google or Internet Search
Facebook/Instagram
Friend or family member
Physician Referral
Other
Please type any comments or questions you may have here:
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