Registration Forms

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 patientaccounts@fertilityandmidwifery.com.

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.


Patient Demographics

Open Form

Patient History

Open Form

Consent for Treatment

Open Form

BRAC Survey

Open Form

HIPPA Contact Form

Open Form

Medical Records Release

Open Form

 

Fertility Consultation Questionnaire

Open Form

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

Open Form


Nutrition Patients

 

Nutrition Counseling & Medical Nutrition Therapy

Open Form

Initial LEAP Patient Health History

Open Form

Initial Symptom Survey

Open Form