Henry Fertility Appointment Request Form

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Here are a couple of things for you to know about how our clinic schedules appointments:

We take the female as the patient, all forms must be filled out with the female information.
We are happy to consult with you as a couple, but it is the female that we ultimately treat.‍
We accept all commercial insurance but do not participate in the Healthy Indiana or Medicaid plans.

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Full Name* This field is required.

First Name

Last Name

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Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Phone* This field is required.

Area Code

Phone Number

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Does this phone number accept text messages?

YESNO

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E-mail* This field is required.

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Please provide the name of your insurance carrier(Example: Anthem)

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Patient Birth Date

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Preferred location/clinic?

201 Pennsylvania Parkway, Suite 325 Carmel, IN 46280 (Main office)

1429 North 6th Street (2nd Floor) Terre Haute, IN 47807 (2nd Wednesday of every month)

3920 East St. Francis Way, Suite 219 Lafayette, IN 47905 (Every other Friday)

642 Walker Street Bloomington, IN 47403 (4th Wednesday of every month)

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What is the reason for your visit?* This field is required.

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Please verify that you are human* This field is required.

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