Thank you for selecting the Fertility and Midwifery Care Center as your partner in healthcare!
In an effort to improve the efficiency of your visit and maximize the time we have together, we ask that you please complete the patient demographics, consent for treatment, patient history, and BRAC survey forms. After completing the forms, please print and bring them with you to your appointment.
If you wish to submit this form electronically, we ask that you save the form to your desktop, fill the form out, save it with your information filled out, and then email the form to firstname.lastname@example.org.
If we are not providers in your insurance network we ask that you also complete the out of network provider waiver form as well.
Thanks in advance for trusting us. We look for to working with you.
Out of Network Provider Waiver
Please Note: You only need to fill this out if we are out of network with your insurance
Cancellation/No Show Policy