New Patient Intake Form

"*" indicates required fields

1Sex-organ specific intake form

2Patient rights and responsibilities

3Consent for Care

4Financial Policy

5Insurance benefits review authorization

6Insurance Waiver Consent

7Credit Card Information

Company

This field is for validation purposes and should be left unchanged.

Sex-organ specific intake form

******************* Step-1 *******************

Primary Patient

Primary Patient*

PATIENTS WITH A UTERUS

PATIENTS WITH A PENIS

By submitting this form, you agree to our Privacy Policy and Terms of Use and consent to receive occasional messages from Coastal Fertility.

Name*

Preferred Name

My pronouns are:*

She/ Her

He/ His

They/Them

What is your gender identity?

Cisgender (identifies with the sex assigned at birth)

Genderqueer

Nonbinary

Transgender

Other

Please Specify*

What is your sexual orientation?*

Please Specify*

Birth date*

Age*

Email*

Occupation

Do you have a Driver's license?

Yes

Driver's license*

Upload Front Driver's license*

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Upload Back Driver's license*

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Do you have a Military ID?

Yes

Military ID*

Upload Front Military ID*

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Upload Back Military ID*

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Do you have a Passport?

Yes

Passport ID*

Upload Front Passport ID*

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Race

Marital Status

Married

Single

Height

Total number pregnancies

Pre-term births

Weight

Term births

Miscarriages/Abortions

Reason for Visit (chief complaint)*

How long have you been trying to achieve a pregnancy? (months of unprotected intercourse or number of insemination cycles)*

How long have you been trying to achieve a pregnancy with current partner?*

Pregnancy Information

How many pregnancies have you had?

Date*

Gender*

Male

Female

Unknown

Current Partner?*

Yes

Months to Conception*

Difficulty Conceiving?*

Yes

Please Specify*

Fertility Treatment?*

Yes

Please Specify*

Outcome*

Please Specify*

Delivery Type*

Vaginal

C-Section

Other

Please Specify*

Date*

Gender*

Male

Female

Unknown

Current Partner?*

Yes

Months to Conception*

Difficulty Conceiving?*

Yes

Please Specify*

Fertility Treatment?*

Yes

Please Specify*

Outcome*

Please Specify*

Delivery Type*

Vaginal

C-Section

Other

Please Specify*

Date*

Gender*

Male

Female

Unknown

Current Partner?*

Yes

Months to Conception*

Difficulty Conceiving?*

Yes

Please Specify*

Fertility Treatment?*

Yes

Please Specify*

Outcome*

Please Specify*

Delivery Type*

Vaginal

C-Section

Other

Please Specify*

Date*

Gender*

Male

Female

Unknown

Current Partner?*

Yes

Months to Conception*

Difficulty Conceiving?*

Yes

Please Specify*

Fertility Treatment?*

Yes

Please Specify*

Outcome*

Please Specify*

Delivery Type*

Vaginal

C-Section

Other

Please Specify*

Date*

Gender*

Male

Female

Unknown

Current Partner?*

Yes

Months to Conception*

Difficulty Conceiving?*

Yes

Please Specify*

Fertility Treatment?*

Yes

Please Specify*

Outcome*

Please Specify*

Delivery Type*

Vaginal

C-Section

Other

Please Specify*

Date*

Gender*

Male

Female

Unknown

Current Partner?*

Yes

Months to Conception*

Difficulty Conceiving?*

Yes

Please Specify*

Fertility Treatment?*

Yes

Please Specify*

Outcome*

Please Specify*

Delivery Type*

Vaginal

C-Section

Other

Please Specify*

Menstrual Cycle History

(Answer these questions about your menstrual (bleeding) pattern).

At what age did you begin having periods?*

When was the date of your last menstrual period?*

What is the average length of time your period lasts?*

What is the average length of time from the start of one period until the start of the next?*

Within the last year, have your periods usually come (without medication) every 26-32 days?*

Yes

Do you often experience pelvic pain in between periods?*

Yes

Do you currently need to take medication in order to get a period?*

Yes

Do you have pelvic pain with your periods?*

Yes

Have you ever used home ovulation predictor kits?*

Yes

Do you use or have you used any contraceptives?*

Yes

Please Specify?*

When they started?*

Are you still using contraceptives?*

Yes

When they stopped?*

Do you ever have bleeding in between periods?*

Yes

Gynecologic History

Have you had a pap smear?*

Yes

It was?*

Normal

Abnormal

If abnormal, how?*

Date*

Is your mammogram current?*

Yes

Do you have any breast discharge?*

Yes

Do you currently have acne?*

Yes

Do you have unwanted (facial, arm, chest, or other male pattern hair growth?*

Yes

What is the number of sexual partners you have had in the past 2 years?*

Do you have a history of sexual abuse?*

Yes

Do you often have pain with Intercourse?*

Yes

How frequently do you have Intercourse?*

Do you use lubricants with Intercourse (oil, saliva, KY Jelly)?*

Yes

Have you ever had any cervical procedures performed?*

Yes

Please select the cervical procedures you have had*

Colposcopy

Cone Biopsy

LEEP procedure

Cryosurgery

Laser treatment

Date*

Findings*

Date*

Findings*

Date*

Findings*

Date*

Findings*

Date*

Findings*

Have you had any exposure to or have been treated for any sexually transmitted disease or pelvic infection?*

Yes

Please specify*

Medical History

What is your blood type?*

Do you have long-standing medical conditions?*

Yes

Please Specify*

Have you ever needed or used thyroid medication?*

Yes

Please Specify*

Are you currently taking any medication?*

Yes

Please Specify*

Dosage?*

Frequency?*

Have you had the following vaccinations?*

Yes

Measles*

Yes

Don’t know

Rubella*

Yes

Don’t know

Hepatitis A*

Yes

Don’t know

Hepatitis B*

Yes

Don’t know

Varicella (Chickenpox)*

Yes

Don’t know

Tuberculosis*

Yes

Don’t know

Polio*

Yes

Don’t know

Tetanus*

Yes

Don’t know

Influenza*

Yes

Don’t know

Are you allergic to or have had any adverse reaction to any medications, foods, or other environmental factors*

Yes

Please list and describe reactions*

Have you had any surgeries?*

Yes

Number of surgeries

Year

Type of surgery

Outcome

Are you currently using acupuncture?*

Yes

Please Specify*

Have you used acupuncture In the past?*

Yes

Please Specify*

Have you had chickenpox?*

Yes

Have you ever been diagnosed with HIV?*

Yes

Do you have a history of an eating disorder?*

Yes

Please Specify*

Environmental Factors

Do you use any nicotine products (cigarettes,cigars, smokeless tobacco, vaping, etc)?*

Yes

How many/day?*

In the past, have you ever use any nicotine products (cigarettes, cigars, smokeless tobacco. vaping, etc)?*

Yes

How many/day?*

Do you drink alcohol?*

Yes

If you drink alcohol*

Beer - # per week

Wine - # per week

Liquor - # per week

Enter beer quantity*

Enter wine quantity*

Enter liquor quantity*

Have you ever had issue with alcohol dependency/abuse?*

Yes

Do you consume caffeinated beverages?*

Yes

If Yes please describe*

Do you use "recreational drugs"?*

Yes

If Yes please describe*

Do you use herbal remedies, vitamins or over the counter medications?*

Yes

If Yes please describe*

Are you on a special diet?*

Yes

If Yes please describe*

Do you currently exercise?*

Yes

If Yes please describe*

Are you worried or concerned about your weight?*

Yes

In the past six months have you traveled to any areas where Zika virus has been present or do you plan to travel to one of these areas in the future?*

Yes

Genetic / Family History

Mother (Living)

Yes

Age*

Cause of Death/Age at Death*

Father (Living)

Yes

Age*

Cause of Death/Age at Death*

Brother (s) (Living)

Yes

N/A

Age*

Cause of Death/Age at Death*

Sister (s) (Living)

Yes

N/A

Age*

Cause of Death/Age at Death*

Maternal Grandmother (Living)

Yes

Age*

Cause of Death/Age at Death*

Maternal Grandfather (Living)

Yes

Age*

Cause of Death/Age at Death*

Paternal Grandmother (Living)

Yes

Age*

Cause of Death/Age at Death*

Paternal Grandfather (Living)

Yes

Age*

Cause of Death/Age at Death*

Does anyone in your family have any medical conditions?*

Yes

Medical Condition

Early menopause (before age 45)

EndometriosIs

Infertility

Recurrent Miscarriage / Pregnancy loss

Diabetes

Mental Retardation - Chromosome? Testing

Mental Retardation - Testing foe Fragile X Mutation

Birth Detects -Chromosomal testing

Delayed puberty or pituitary tumor

Breast Cancer

Ovarian Cancer

Cervical Cancer

Uterine Cancer

Bowel Cancer

Colon Cancer

Anemia

Bleeding Disorder

Autism

Chromosome Disorder (e.g. Down's syndrome)

Muscular Dystrophy

Hemophilia

Huntington's Disease

Polycysfic Kidney Disease

Neural Tube Defect

Neurofibromatosts

Marian Syndrome

Thyroid Disease

Celiac Disease

Hypertension

Asthma

Kidney Disease

Do you have a birth defect or familial disorder not listed above?

Yes

If yes, Please specify?*

Have you or your significant other in this or any previous relationship had a stillborn child or more than two first trimester miscarriages?

Yes

What is your mother's ancestry?

What is your father's ancestry?

Eastern European /Jewish Ancestry

Have you had a Tay Sach's screening test?

Yes

When?*

What were the findings?*

Normal

Abnormal

Have you had a Canavan Screening Test?

Yes

When?*

What were the findings?*

Normal

Abnormal

Have you had a Bloom Screening Test?

Yes

When?*

What were the findings?*

Normal

Abnormal

Have you had a Gauche, Screening Test?

Yes

When?*

What were the findings?*

Normal

Abnormal

Have you had a Fanconl Anemia Screening Test?

Yes

When?*

What were the findings?*

Normal

Abnormal

Have you had a Nelmann-Pick Screening Test?

Yes

When?*

What were the findings?*

Normal

Abnormal

African Ancestry

Have you had a Sickle cell screening test?

Yes

When?*

What were the findings?*

Normal

Abnormal

European Ancestry or Family member with cystic fibrosis

Have you been tested for Cystic Fibrosis?

Yes

When?*

What were the findings?*

Normal

Abnormal

Italian, Greek, Mediterranean or Southeast Asian ancestry

Have you had screening for inherited forms of anemia such as Thalassemia?

Yes

When?*

What were the findings?*

Normal

Abnormal

Infertility Tests

Have you had any of the following fertility tests/ in the past?*

Yes

Ultrasound of the uterus and/or ovaries when NOT pregnant?

When?*

Findings*

Normal Uterus

Blocked fallopian tube/tubes

Other

Please Specify*

Hysterosalpingogram (HSG)? An x-ray test of the uterus during which dye Is Injected into the uterus to "see" it

When?*

Findings*

Normal Uterus

Blocked fallopian tube/tubes

Other

Please Specify*

Hysterosonogram (also called sonohysterogram)? An ultrasound test in which saline (salt water is injected and an ultrasound is used to "see" the uterus.

When?*

Findings*

Normal Uterus

Blocked fallopian tube/tubes

Other

Please Specify*

Laparoscopy? A telescope is placed through the belly button to see inside your abdomen

How many Laparoscopy tests you have?

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Hysteroscopy? A telescope is placed through the vagina into the uterus In order to see the inside of the uterus.

How many Hysterosoopy tests you have?

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Date*

Indication*

Surgery*

Findings*

Complications*

Yes

Other tests to specifically look al possible causes of infertility, miscarriage or problems with menstrual cycle?

Test

Day 3 FSH

Date*

Results*

Test

Day 3 Estradiol

Date*

Results*

Test

CCCT – Day 3 FSH

Date*

Results*

Test

CCCT – Day 10 FSH

Date*

Results*

Test

Semen Analysis (Partner)

Date*

Results*

Test

Blood Test to verify ovulation

Date*

Results*

Test

Basal Body Temperature Chart (BBT)

Date*

Results*

Test

Endometrial Biopsy

Date*

Results*

Test

Inhibin

Date*

Results*

Post Coital Test

Date*

Results*

Anti-sperm antibodies (Female)

Anti-sperm antibodies (Female

Date*

Results*

Chromosome Analysis (Karyotype) - Female

Date*

Results*

Chromosome Analysis (Karyotype) - Male Partner

Date*

Results*

Anti-Phospholipld Antibodies

Date*

Results*

Lupus-Anticoagulant

Date*

Results*

TSH

Date*

Results*

Prolactin

Date*

Results*

Date*

Results*

Progesterone

Date*

Results*

Antimullerian Hormone (AMH)

Date*

Results*

Factor V Leiden Mutation

Date*

Results*

Prothrombin Mutation

Date*

Results*

testosterone

Date*

Results*

Other

Date*

Results*

Past Fertility Treatments

Have you ever had any Clomlphene citrate (Clomid, Serophene) cycle?

Yes

How many Clomlphene citrate (Clomid, Serophene) cycle you have?

Date*

Dose*

1 pill = 50 mg , 2 pills = 100 mg

Monitoring*

Suno= ultrasound

Method of Sperm Delivery*

IUI = Insemination or placement of sperm Into the uterus

Complications*

Please explain

Outcome ?*

OHSS = Ovarian Hyperstimulation Syndrome

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose*

1 pill = 50 mg , 2 pills = 100 mg

Monitoring*

Suno= ultrasound

Method of Sperm Delivery*

IUI = Insemination or placement of sperm Into the uterus

Complications*

Please explain

Outcome ?*

OHSS = Ovarian Hyperstimulation Syndrome

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose*

1 pill = 50 mg , 2 pills = 100 mg

Monitoring*

Suno= ultrasound

Method of Sperm Delivery*

IUI = Insemination or placement of sperm Into the uterus

Complications*

Please explain

Outcome ?*

OHSS = Ovarian Hyperstimulation Syndrome

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose*

1 pill = 50 mg , 2 pills = 100 mg

Monitoring*

Suno= ultrasound

Method of Sperm Delivery*

IUI = Insemination or placement of sperm Into the uterus

Complications*

Please explain

Outcome ?*

OHSS = Ovarian Hyperstimulation Syndrome

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose*

1 pill = 50 mg , 2 pills = 100 mg

Monitoring*

Suno= ultrasound

Method of Sperm Delivery*

IUI = Insemination or placement of sperm Into the uterus

Complications*

Please explain

Outcome ?*

OHSS = Ovarian Hyperstimulation Syndrome

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose*

1 pill = 50 mg , 2 pills = 100 mg

Monitoring*

Suno= ultrasound

Method of Sperm Delivery*

IUI = Insemination or placement of sperm Into the uterus

Complications*

Please explain

Outcome ?*

OHSS = Ovarian Hyperstimulation Syndrome

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Have you ever had any Gonadotropins (Pergonal, Hamelin, Repronex. Hurnegon, Fertinex, Gonal-F, Follistm, Cetraide, Antagon, Lupron) cycle?

Yes

How many Gonadotropins (Pergonal, Hamelin, Repronex. Hurnegon, Fertinex, Gonal-F, Follistm, Cetraide. Antagon. Lupron) cycle you have?

Date*

Dose (Amps/Vials per day)*

Medication*

No. of days*

Method of Sperm Delivery*

Intercourse

IUI

Complications*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose (Amps/Vials per day)*

Medication*

No. of days*

Method of Sperm Delivery*

Intercourse

IUI

Complications*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose (Amps/Vials per day)*

Medication*

No. of days*

Method of Sperm Delivery*

Intercourse

IUI

Complications*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose (Amps/Vials per day)*

Medication*

No. of days*

Method of Sperm Delivery*

Intercourse

IUI

Complications*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose (Amps/Vials per day)*

Medication*

No. of days*

Method of Sperm Delivery*

Intercourse

IUI

Complications*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Dose (Amps/Vials per day)*

Medication*

No. of days*

Method of Sperm Delivery*

Intercourse

IUI

Complications*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Have you ever had any In-Vitro FertIllzatIon(IVF) cycle?

Yes

How many In-Vitro FertIllzatIon(IVF) cycle you have?

Date*

Egg Source*

Own

Donor

Medication*

Dose (Amps/Vials per day)*

ICSI*

Yes

No. of Eggs*

No. fertilized of eggs*

Transfer Day*

No. of embryos transferred*

Number frozen*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Egg Source*

Own

Donor

Medication*

Dose (Amps/Vials per day)*

ICSI*

Yes

No. of Eggs*

No. fertilized of eggs*

Transfer Day*

No. of embryos transferred*

Number frozen*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Egg Source*

Own

Donor

Medication*

Dose (Amps/Vials per day)*

ICSI*

Yes

No. of Eggs*

No. fertilized of eggs*

Transfer Day*

No. of embryos transferred*

Number frozen*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Egg Source*

Own

Donor

Medication*

Dose (Amps/Vials per day)*

ICSI*

Yes

No. of Eggs*

No. fertilized of eggs*

Transfer Day*

No. of embryos transferred*

Number frozen*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Egg Source*

Own

Donor

Medication*

Dose (Amps/Vials per day)*

ICSI*

Yes

No. of Eggs*

No. fertilized of eggs*

Transfer Day*

No. of embryos transferred*

Number frozen*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Egg Source*

Own

Donor

Medication*

Dose (Amps/Vials per day)*

ICSI*

Yes

No. of Eggs*

No. fertilized of eggs*

Transfer Day*

No. of embryos transferred*

Number frozen*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Have you ever had any Frozen Embryo cycle?

Yes

How many Frozen Embroy cycle you have?

Date*

Natural or Medicated Cycle*

Natural

Medicated

Transfer Day*

# Thawed*

# Survived*

# Transferred*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Natural or Medicated Cycle*

Natural

Medicated

Transfer Day*

# Thawed*

# Survived*

# Transferred*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Natural or Medicated Cycle*

Natural

Medicated

Transfer Day*

# Thawed*

# Survived*

# Transferred*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Natural or Medicated Cycle*

Natural

Medicated

Transfer Day*

# Thawed*

# Survived*

# Transferred*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Natural or Medicated Cycle*

Natural

Medicated

Transfer Day*

# Thawed*

# Survived*

# Transferred*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Date*

Natural or Medicated Cycle*

Natural

Medicated

Transfer Day*

# Thawed*

# Survived*

# Transferred*

Outcome ?*

Pregnancy

No ovulation

No pregnancy

OHSS

Birth Defect

Abortion

Miscarriage <20 wks

Delivery Type ?*

Vaginal

C-Section

Other

Have you ever had any Gestational Surrogacy cycles?

Yes

Have you ever been an egg donor?

Yes

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Name*

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Preferred Name*

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My pronouns are:*

She/ Her

He/ His

They/Them

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What is your gender identity?

Cisgender (identifies with the sex assigned at birth)

Genderqueer

Nonbinary

Transgender

Other

This field is hidden when viewing the form

Please Specify*

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What is your sexual orientation?*

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Please Specify*

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Birth Date*

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Age*

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Occupation*

This field is hidden when viewing the form

Do you have Driver's license?

Yes

This field is hidden when viewing the form

Do you have Military ID?

Yes

This field is hidden when viewing the form

Do you have Passport?

Yes

Driver's license*

Upload Front Driver's license*

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Upload Back Driver's license*

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Military ID*

Upload Front Military ID*

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Upload Back Military ID*

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Passport ID*

Upload Front Passport ID*

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Race*

Height*

Weight*

Recent changes in weight?

Yes

Medical History

Do you have long-standing medical conditions?*

Yes

If yes, please list*

Are you currently taking any medication?*

Yes

Please Specify*

Dosage?*

Frequency?*

Do you use herbal remedies, vitamins or over the counter medications?*

Yes

If yes, please list*

Are you on a special diet?*

Yes

Please Specify*

Have you had any exposure to or have been treated for any sexually transmitted disease or infection*

Yes

Please Specify*

Are you allergic to or have had an adverse reaction to any medications, foods, or other environmental factors?*

Yes

Please list and describe reactions*

Have you had any surgeries?*

Yes

Number of surgeries

Year

Type of surgery

Outcome

Have you had mumps?*

Yes

Do you have any difficulty with erections*

Yes

Please Specify*

Do you have any difficulty with ejaculation?*

Yes

Please Specify*

Have you ever been unable to impregnate a female partner?*

Yes

Have you ever been a sperm donor?*

Yes

Have you ever taken testosterone. pre-testosterone supplements, hormone treatments and other steroids?*

Yes

Please Specify*

Have you ever had vasectomy?*

Yes

Please Specify*

Have you ever had surgery to testicles?*

Yes

Please Specify*

Have you had undescended testicles?*

Yes

Please Specify*

Have you had trauma to the testicles?*

Yes

Please Specify*

Have you had painful swelling of the testicles?*

Yes

Please Specify*

Have you had torsion (twisting) of the testicles?*

Yes

Please Specify*

Have you ever had white blood cells In your semen?*

Yes

Please Specify*

Have you ever had a prostate Infection?*

Yes

Please Specify*

Environmental Factors

Do you use any nicotine products (cigarettes,ffigars, smokeless tobacco, vaping, etc*

Yes

How many/day?*

In the past, have you ever use any nicotine products (cigarettes, cigars, smokeless tobacco, vaping, etc)?*

Yes

How many/day?*

Do you drink alcohol?*

Yes

If you drink alcohol*

Beer - # per week

Wine - # per week

Liquor - # per week

Enter beer quantity*

Enter wine quantity*

Enter liquor quantity*

Have you over had Issue with alcohol dependency/abuse?*

Yes

Do you consume caffeinated beverages?*

Yes

Please Specify*

Do you use "recreational" drugs?*

Yes

Please Specify*

Do you take baths or use hot tubs?*

Yes

Have you had a high fever recently?*

Yes

Are you exposed to any chemicals?*

Yes

Please Specify*

In the past six months have you traveled to any areas where Zika virus has been present or do you plan to travel to one of these areas In the future?*

Yes

Genetic / Family History

Does anyone in your family have any of the following medical conditions?*

Yes

Medical Condition

Early menopause (before age 45)

EndometriosIs

Infertility

Recurrent Miscarriage / Pregnancy loss

Diabetes

Mental Retardation - Chromosome? Testing

Mental Retardation - Testing foe Fragile X Mutation

Birth Detects -Chromosomal testing

Delayed puberty or pituitary tumor

Breast Cancer

Ovarian Cancer

Cervical Cancer

Uterine Cancer

Bowel Cancer

Colon Cancer

Anemia

Bleeding Disorder

Autism

Chromosome Disorder (e.g. Down's syndrome)

Muscular Dystrophy

Hemophilia

Huntington's Disease

Polycysfic Kidney Disease

Neural Tube Defect

Neurofibromatosts

Marian Syndrome

Thyroid Disease

Celiac Disease

Hypertension

Asthma

Kidney Disease

Do you have a birth defect or familial disorder not listed above?

Yes

If yes, Please specify?*

Have you or your significant other in this or any previous relationship had a stillborn child or more than two first trimester miscarriages?

Yes

What is your mother's ancestry?

What is your father's ancestry?

Eastern European /Jewish Ancestry

Have you had a Tay Sach's screening test?

Yes

When?

What were the findings?

Normal

Abnormal

Have you had a Canavan Screening Test?

Yes

When?

What were the findings?

Normal

Abnormal

Have you had a Bloom Screening Test?

Yes

When?

What were the findings?

Normal

Abnormal

Have you had a Gauche, Screening Test?

Yes

When?

What were the findings?

Normal

Abnormal

Have you had a Fanconl Anemia Screening Test?

Yes

When?*

What were the findings?

Normal

Abnormal

Have you had a Nelmann-Pick Screening Test?

Yes

When?

What were the findings?

Normal

Abnormal

African Ancestry

Have you had a Sickle cell screening test?

Yes

When?

What were the findings?

Normal

Abnormal

European Ancestry or Family member with cystic fibrosis

Have you been tested for Cystic Fibrosis?

Yes

When?

What were the findings?

Normal

Abnormal

Italian, Greek, Mediterranean or Southeast Asian ancestry

Have you had screening for inherited forms of anemia such as Thalassemia?

Yes

When?

What were the findings?

Normal

Abnormal

Male Infertility Tests

Have you or your past or present female partner(s) ever participated in fertility treatment?*

Yes

Have you ever had fertility medications (hormone, etc.)?

Yes

Have you ever been seen by a urologist or male infertility expert?

Yes

Have you had surgery to correct a sperm problem?

Yes

Have you had an ultrasound of the testicles?

Yes

Have you had blood tests for infertility?

Yes

Have you had sperm chromatin (DNA Fragmentation — SCSA) test?

Yes

Have you had a semen analysis test?

Yes

Have you had a sperm penetration assay?

Yes

Have you had a acrosome reaction test?

Yes

Have you had a chromosome analysis (karyotype) test

Yes

Have you had an evaluation of Y hromosome deletion?

Yes

Patient Rights and Responsibilities

******************* Step-2 *******************

PATIENT RIGHTS

You have the right to reasonable response to requests for treatment or services.
You have the right to considerate and respectful care including consideration of psychosocial, spiritual, or cultural concerns.
You have the right to information necessary to make an informed decision, to consent or refuse treatment, referral, or transfer.
You have the right to information about your rights, availability, and how to obtain services, patient responsibilities, and grievance procedures.
You have the right to participate in discussions of ethical issues that arise in the course of your care.
You have the right to be informed, and consent to or refuse participation in research and/or educational projects.
You have the right to personal privacy.
Your guardian, next of kin, or legally authorized responsible person retains all rights if you are incapacitated.
You have the right to receive care in a safe and secure environment.
You have the right, in collaboration with your physician, to make decisions involving your care, including the right to Organ Donation and to formulate Advanced Directives.
You have the right to change providers if other qualified providers are available.
Interpreters available upon request

PATIENT RESPONSIBILITIES

Provide, to the best of your knowledge, accurate and complete information regarding your medical history, including medications and any allergies or sensitivities.
Ask questions about those diagnoses, procedures and treatments if you do not fully understand.
Follow the treatment plan recommended by your physician including medications, diet and personal habits, which affect health, or assume the responsibility for failure to do so.
Report changes in condition to your provider.
Inform clinic staff at the time of your admission if you have an advance directive (living will or durable power of attorney for health care), and provide a copy to be included in your medical file.
Observe all clinic regulations that are designed for the comfort and safety of all patients and staff, such as fire, safety, noise and infection control regulations.
Be considerate of other patients and clinic personnel by not making unnecessary noise, using civil language and conduct, not smoking or causing distractions, not having clinic personnel look after your child(ren).
Keep appointments or notify the clinic if unable to do so.
Provide a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, if required by the provider.
Accept personal financial responsibility for any charges not covered by your insurance.
Be respectful of all health care professionals and staff, as well as other patients.

By signing below, I confirm that I have read and understand the above stated information provided by Coastal Fertility

Patient Name*

Date*

Signature*

General Consent for Care and Treatment

******************* Step-3 *******************

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid level provider (Nurse, Medical Assistant, etc.), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents

Signature of Patient*

Date*

Name of Patient*

Name of Witness (Office Staff )

Office Staff Job Title

Date

New Patient Intake Form

Sex-organ specific intake form

Pregnancy Information

Menstrual Cycle History

Gynecologic History

Medical History

Environmental Factors

Genetic / Family History

Infertility Tests

Past Fertility Treatments

Medical History

Environmental Factors

Genetic / Family History

Male Infertility Tests

Patient Rights and Responsibilities

PATIENT RIGHTS

PATIENT RESPONSIBILITIES

General Consent for Care and Treatment

Financial Policy

Insurance benefits review authorization

Insurance Waiver Consent

CREDIT CARD INFORMATION

About Coastal Fertility

Quick Links

Address

You’re all set!

Send us a message, we’ll be happy to answer any questions!

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