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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, the majority of your registration paperwork will need to be completed through the Patient Portal, which can be done up to 7 days prior to your appointment.  The forms below may also need to be filled out depending on the services you receive at our office.  Additionally, you have the option to fill out the BRAC survey online.

Get Started

Download your forms

To download a form, click the corresponding button below. You can either print the form and fill it out by hand, or save it to your computer and submit it via the Patient Portal prior to your appointment.

Fill out the forms

Please complete the Patient History form and the BRAC survey. If we are not providers in your insurance network, we ask that you also complete the out-of-network provider waiver form as well. Documents submitted electronically must be E-Signed. Please be sure to open the downloaded PDF in Adobe Reader (a standard, free app on most computers) and complete the electronic signature at the bottom of each form before sending.

Send the completed forms

If you printed your forms out, please bring them with you to your appointment. Digital forms can be submitted via a message on the Patient Portal prior to your appointment.

General Patient Forms

Obstetrical History

BRAC Survey

Medical Records Release

Fertility Consultation Questionnaire

Out of Network Provider Waiver

Infertility Patient Forms

If you will be seeing our office for fertility-related issues please read the document below & watch the video.

Infertility Document

The Menstrual Cycle

Nutrition Patient Form

Initial Symptom Survey

Initial LEAP Patient Health History

LEAP Client Consultation Contract

Nutrition Counseling & Medical Nutrition Therapy

Physical & Occupational Therapy Patient Form

Female Physical Therapy Pelvic Questionnaire

Internal Pelvic Floor Eval Consent Form

Pelvic Male Dysfunction Questionnaire

Female Occupational Therapy Pelvic Questionnaire

Medical Records Release

Out of Network Provider Waiver