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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, we ask that you please complete the New Patient Packet and take the online BRAC survey.

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 email prior to your appointment.

Fill out the forms

Please complete the New Patient Packet 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 via email 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 emailed to prior to your appointment.

General Patient Forms

New Patient Packet

BRAC Survey

Patient Demographics

Consent for Treatment

HIPPA Contract Form

Patient History

Cancellation/ No Show

FMLA & Disability Policy

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 Therapy Patient Form

Female Pelvic Questionnaire

Internal Pelvic Floor Eval Consent Form

Pelvic Male Dysfunction Questionnaire

Cancellation No Show Policy

Patient Demographics

HIPPA Contact Form

Medical Records Release

Out of Network Provider Waiver

Consent for Treat, Agree to Pay, Assignments of Benefits, Acknowledgement and Release