LGBTQ+ friendly fertility clinic.

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New Patient Forms

Please find our electronic new patient forms below. We prefer these are completed securely online as the physicians prefer to receive them 5-7 business days prior to your appointment.

If you are unable to complete the forms online, please click here to download all forms in Adobe Reader®. If you have any questions about the forms, please please contact us.

Download Forms

I’m the patient and I have a Uterus, my partner has a Penis (U-P)
I’m the patient and I have a Uterus, my partner has a Uterus (U-U)
I’m the patient and I have a Penis, my partner has a Uterus (P-U)
I’m the patient and I have a Penis, my partner has a Penis (P-P)
I’m the patient and I have a Uterus, I don’t have a partner (U-N)
I’m the patient and I have a Penis, I don’t have a partner (P-N)

Download Forms

1Contact Information

2Infertility History

3Email Consent

4Privacy Notice

5Credit Card Authorization Agreement Form

Contact Information
Patient
First Name*
Last Name*
Middle Initial
Marital Status
Best Ph # To Reach You*
OK to leave a message?
- Yes
- No
2nd Best Ph # To Reach You
OK to leave a message?
- Yes
- No
Date Of Birth*

MM slash DD slash YYYY
E-mail*
Age*
Address*
City*
State*
Zip Code*
DRIVER'S LIC
State
Occupation
Work Hours
Employer
City
State
Zip Code
Do You have Partner ?
- Yes
- No
Partner
First Name*
Last Name*
Middle Initial
Marital Status
Best Ph # To Reach You*
OK to leave a message?
- Yes
- No
2nd Best Ph # To Reach You
OK to leave a message?
- Yes
- No
Address*
City*
State*
Zip Code*
Date Of Birth*

MM slash DD slash YYYY
Age*
DRIVER'S LIC
ST
E-mail*
Occupation
Work Hours
Employer
Employer Address
City
State
Zip Code
Referral information
WHOM MAY WE THANK FOR THIS REFERRAL?*
Friend (Name)*
Physician (Name)*
Internet*
Support Group*
Attended Seminar
Insurance information
Please note that Coastal Fertility Medical Center is not a participating provider with major medical insurance companies. We will only use your insurance information to reference or verify ancillary services, such as surgical centers outside our facilities.
- I don’t have insurance
Patient
PRIMARY INS*
Insured’s Name*
Insurance ID*
Type*
WHICH MEDICAL GROUP ARE YOU ASSIGNED TO?
ID#
GRP #
CLAIMS ADDR*
City*
State*
Zip Code
Phone*
Do you have partner ?
- Yes
- No
Emergency contact person (not living with you)
Relationship
Partner
PRIMARY INS
Insured’s Name
Insured
Do you have document to upload ?
- Yes
- No
Upload Front Insurance*
Accepted file types: jpg, png, pdf, Max. file size: 64 MB.
Upload Back Insurance*
Accepted file types: jpg, png, pdf, Max. file size: 64 MB.
WHICH MEDICAL GROUP ARE YOU ASSIGNED TO?
ID#
GRP #
CLAIMS ADDR*
City*
State*
Zip Code
Phone*
Patient's signature*
Partner's signature
Date*

MM slash DD slash YYYY
Date (Partner's )

MM slash DD slash YYYY

Save and send link for partner to sign

CONTACT INFORMATION
Primary Patient
Primary Patient*
- Has a Uterus
- Has a Penis
Untitled
- Same as previous
First Name*
Middle Initial
Last Name*
Age*
Date of Birth*

MM slash DD slash YYYY
Occupation
Home Street Address*
City*
State*
Zip/Postal Code*
Country*
E-mail*
PATIENT MEDICAL HISTORY AND INFORMATION
Reason for Visit*
- Infertility Evaluation
- Sperm Insemination
- Endometriosis/PCOS
- Other
Reason for Visit (Other)*
What are your expectations for this visit?*
Any questions you wish to address*
Do you have any personal, ethical, or relations objections to any of our tests or treatments such as insemination, in vitro fertilization, egg donation, sperm donation, masturbation to collect a semen sample, etc.?*
- Yes
- No
How many months have you been having intercourse without using any form of birth control?*
Pregnancy History
Number of ALL Pregnancies
Number of Miscarriages (less than 20 weeks)*
Number of Ectopic / Tubal Pregnancies*
Number of Elective Terminations (Abortions)*
Number of Full Term Deliveries*
Of these, how many were live births?*
How many were stillborn?*
Number of Premature (less than 37 weeks) Deliveries*
How many were stillborn?*
Any Pregnancies with Birth Defects?*
- Yes
- No
If yes, please explain*

Pregnancy History Details	Months to Conception	Treatments to Conceive	Delivery Type/D&C/Complications	Current Partner? (Yes/No)

Menstrual Cycle History
Menstrual cycle pattern (check all that apply):
- Regular periods
- Irregular periods
- Spotting before periods
- No periods
- Heavy periods
- Light periods
- Bleeding between periods
Number of days between the start of one period to the start of the next period*
How many days of bleeding do you have?*
Dates of the 1st day of your last 2 menstrual periods*
Age when you had your first period*
How many periods do you have per year?*
Do you need medication to bring on a period?*
- Yes
- No
If you do not have periods, at what age did you stop having them?*
If Yes*
Do you have severe cramping or pelvic pain with your periods?*
- Yes
- No
Always __ Sometimes __ Recently __In the past
Sexual History
How many times do you have intercourse per week?*
Have you used over-the-counter ovulation kits to time intercourse*
- Yes
- No
Do you have pain with intercourse?*
- Yes
- No
Have you had any of the following sexually transmitted diseases or pelvic infections?*
- Chlamydia
- Gonorrhea
- Herpes
- Genital warts/HPV
- Syphilis
- HIV/AIDS
- Hepatitis
- Other
Chlamydia – Date*

MM slash DD slash YYYY
Gonorrhea – Date*

MM slash DD slash YYYY
Herpes – Date*

MM slash DD slash YYYY
Genital warts/HPV – Date*

MM slash DD slash YYYY
Syphilis – Date*

MM slash DD slash YYYY
HIV/AIDS – Date*

MM slash DD slash YYYY
Hepatitis – Date*

MM slash DD slash YYYY
Other*
Other – Date*

MM slash DD slash YYYY
Pap Smear Medical History
When was your last pap smear (month and year ) ?*

MM slash DD slash YYYY
- Normal
- Abnormal
When was your last abnormal pap smear?
Have you undergone any procedures as a result of an abnormal pap smear?
- Yes
- No
Yes (check all that apply)
- Colposcopy
- Cryosurgery (Freezing)
- Laser treatment
- Conization
- Leep procedure
Breast Screening History
Have you ever had a mammogram?
- Yes
- No
Date

MM slash DD slash YYYY
Result
- Normal
- Abnormal
Do you perform self breast exams?*
- Yes
- No
Medical History
Are you allergic to any medications?
- Yes
- No
Are you allergic to any foods (peanuts, eggs, etc.)?
- Yes
- No
Please list and describe reactions*
Do you take any medication?
- Yes
- No
If yes, please list*
Do you take any herbal medicines/vitamins or health food store supplements?
- Yes
- No
Please list*
Do you have any medical problem(s)?
- Yes
- No
Please list type, dates, and treatments.*
Social History
How many caffeinated beverages (coffee, tea, soda) do you drink per day?
Do you smoke cigarettes?
- Yes
- No
How many/day?
Quit – when?
Do you drink alcohol?
- Yes
- No
Surgical History
Have you had any surgeries?
- Yes
- No
Number of surgeries

Year	Type of surgery in chronological

Did you have any anesthesia problems?
- Yes
- No
Describe
Physical Symptoms
None of these Issues
- None of these Issues
General
- Diabetes
- Hair loss
- Anorexia/Bulimia
- Lack of energy
- Fever/chills
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Head, Eyes, Ears, Nose, and Throat
- Dizziness
- Loss of sense of smell
- Headaches
- Chronic nasal congestion
- Blurred vision
- Ringing ears
- Hearing loss/deafness
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Respiratory
- Shortness of breath
- Asthma
- Bronchitis
- Pneumonia
- Tuberculosis
- Bloody cough
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Endocrine/Hormonal
- Recent weight gain or loss
- Thyroid gland problems
- Rapid weight gain or loss
- Excessive hunger/thirst
- Temperature intolerance-hot flashes or feeling cold
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Breasts
- Discharge
- Lumps
- Abnormal mammogram
- Reduction
- Augmentation/Breast Implants
- Other
- None
Describe so it’s consistent with the others
- Saline
- silicone
Describe so it’s consistent with the others – do for all similar responses
Neurological Problems
- Weakness/Loss of balance
- Seizures/Epilepsy
- Headaches
- Migraine headaches
- Numbness
- Memory Loss
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Gastrointestinal
- Nausea/Vomiting
- Ulcers
- Hepatitis
- Diarrhea
- Blood in your stools
- Irritable Bowel Syndrome
- Change in bowel habits
- Colitis (ulcerative or Cohn’s)
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Genito-Urinary
- Bladder infections
- Kidney infections
- Vaginal infections
- Frequent urination
- Blood in the urine
- Leaking Urine
- Herpes
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Skin/Extremities
- Unexplained rash/inflammation
- Acne
- Skin caner
- Burn injury
- Moles changing in appearance
- Excess hair growth
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Musculoskeletal
- Unusual muscle weakness
- Decreased energy/stamina
- Rheumatoid arthritis
- Lupus Erythematosus
- Myasthenia gravis
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Hematologic
- Blood clotting disorder/Blood clot
- Sickle Cell Anemia
- Thrombophlebitis
- Easy bruising
- Swollen glands/lymph nodes
- Blood transfusions
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Cardiovascular
- Palpitations/Skipped beats
- Chest pain
- Heart attack
- Stroke
- Murmurs
- High blood pressure
- Rheumatic fever
- Mitral valve prolapse
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Mental Health Problems
- Depression
- Anxiety disorder
- Schizophrenia
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Disorders in Your Family
Breast cancer
- Yes
- No
- Don’t Know
If yes, please list relationship to you*
Ovarian cancer
- Yes
- No
- Don’t Know
If yes, please list relationship to you*
Other cancer
- Yes
- No
- Don’t Know
If yes, please list relationship to you*
PRIOR INFERTILITY TESTING AND TREATMENT
*Have you had prior infertility testing or treatment elsewhere?
- Yes
- No
Prior Tests (check all that apply):*
- Basal body temperature chart
- Thyroid test
- Ovulation test
- Day 3 blood test for FSH level
- Hysterosalpingogram (HSG)
- Laparoscopy
- Hysteroscopy surgery
- Progesterone blood test
- Prolactin blood test kit
- None of these
Thyroid test
Date*

DD slash MM slash YYYY
Results*
Ovulation test
Date*

DD slash MM slash YYYY
Results*
Day 3 blood test for FSH level
Date*

DD slash MM slash YYYY
Results*
Hysterosalpingogram (HSG)
Date*

DD slash MM slash YYYY
Results*
Laparoscopy
Date*

DD slash MM slash YYYY
Results*
Hysteroscopy surgery
Date*

DD slash MM slash YYYY
Results*
Progesterone blood test
Date*

DD slash MM slash YYYY
Results*
Prior Treatment (Check all that apply):*
- Intrauterine insemination
- Clomiphene citrate with timed intercourse
- Clomiphene citrate with insemination
- Daily fertility drug injections with insemination
- Completed in vitro fertilization cycle(s)
- Frozen embryo transfers
- None of these
Intrauterine insemination
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Clomiphene citrate with timed intercourse
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Clomiphene citrate with insemination
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Daily fertility drug injections with insemination
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Completed in vitro fertilization cycle(s)
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

# of eggs	# of embryos transferred	# frozen

Frozen embryo transfers
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

# of eggs	# of embryos transferred	# frozen

Cancelledin vitro fertilization attempt(s): # of cycles*
Any other prior treatment (describe)
Additional Information/Complications:
I confirm that I have reviewed the information above:
Reason for Visit*
- Infertility Evaluation
- Sperm Insemination
- Endometriosis/PCOS
- Other
Reason for Visit (Other)*
What are your expectations for this visit?*
Any questions you wish to address*
List current medications
List any current medical problem(s)
How many caffeinated beverages (coffee, tea, soda) do you drink per day?
Do you smoke cigarettes?
- Yes
- No
- Quit
How many/day?
How many years ?
When
Do you drink alcohol?
- Yes
- No
Liquor*
- Beer
- Wine
- Liquor
Per week*
Do you use marijuana, cocaine, or any other similar drug?
- Yes
- No
Describe
Do you exercise?
- Yes
- No
Describe
Physician Notes (for office use only)
Have you been evaluated by a urologist?
- Yes
- No
Have you previously conceived with another woman?
- Yes
- No
How many times?
Birth control used?
- Yes
- No
Have you had a semen analysis?
- Yes
- No
Do you have difficulty with erections?
- Yes
- No
Do you have retrograde ejaculation of sperm into the bladder?
- Yes
- No
Have you had any of the following sexually transmitted diseases or pelvic infections?
- Yes
- No
Check all that apply
- Chlamydia
- Gonorrhea
- Herpes
- Genital warts/HPV
- Syphilis
- HIV/AIDS
- Hepatitis
- Other
Other
Any medications?
Have you had a vasectomy?
- Yes
- No
Date*

MM slash DD slash YYYY
Have you had a vasectomy reversal?
- Yes
- No
Date*

MM slash DD slash YYYY
Have you had hernia surgery?
- Yes
- No
Date*

MM slash DD slash YYYY
Did you undergo any bladder or penis surgery as a child?
- Yes
- No
Date*

MM slash DD slash YYYY
Have you had chemotherapy for cancer?
- Yes
- No
Date*

MM slash DD slash YYYY
You allergic to any medications?
- Yes
- No
Date*

MM slash DD slash YYYY
SPOUSE/MALE PATIENT'S SIGNATURE*
Date(Male Patient)*

MM slash DD slash YYYY
Do you have a spouse/partner?*
- Yes
- No
- Other
If other
PARTNER MEDICAL HISTORY AND INFORMATION
My Partner has—
- My Partner has a Uterus
- My partner has a penis
Partner
Do you have any personal, ethical, or relations objections to any of our tests or treatments such as insemination, in vitro fertilization, egg donation, sperm donation, masturbation to collect a semen sample, etc.?*
- Yes
- No
If yes, please explain*
How many months have you been having intercourse without using any form of birth control?*
Pregnancy History
Number of ALL Pregnancies
Number of Miscarriages (less than 20 weeks)*
Number of Ectopic / Tubal Pregnancies*
Number of Elective Terminations (Abortions)*
Number of Full Term Deliveries*
Of these, how many were live births?*
How many were stillborn?*
Number of Premature (less than 37 weeks) Deliveries*
How many were stillborn?*
Any Pregnancies with Birth Defects?*
- Yes
- No
If yes, please explain*

Pregnancy History Details	Months to Conception	Treatments to Conceive	Delivery Type/D&C/Complications	Current Partner? (Yes/No)

Menstrual Cycle History
Menstrual cycle pattern (check all that apply):
- Regular periods
- Irregular periods
- Spotting before periods
- No periods
- Heavy periods
- Light periods
- Bleeding between periods
Number of days between the start of one period to the start of the next period*
How many days of bleeding do you have?*
Dates of the 1st day of your last 2 menstrual periods*
Age when you had your first period*
How many periods do you have per year?*
Do you need medication to bring on a period?*
- Yes
- No
If you do not have periods, at what age did you stop having them?*
If Yes*
Do you have severe cramping or pelvic pain with your periods?*
- Yes
- No
Always __ Sometimes __ Recently __In the past
Sexual History
How many times do you have intercourse per week?*
Have you used over-the-counter ovulation kits to time intercourse*
- Yes
- No
Do you have pain with intercourse?*
- Yes
- No
Have you had any of the following sexually transmitted diseases or pelvic infections?*
- Chlamydia
- Gonorrhea
- Herpes
- Genital warts/HPV
- Syphilis
- HIV/AIDS
- Hepatitis
- Other
Chlamydia – Date*

MM slash DD slash YYYY
Gonorrhea – Date*

MM slash DD slash YYYY
Herpes – Date*

MM slash DD slash YYYY
Genital warts/HPV – Date*

MM slash DD slash YYYY
Syphilis – Date*

MM slash DD slash YYYY
HIV/AIDS – Date*

MM slash DD slash YYYY
Hepatitis – Date*

MM slash DD slash YYYY
Other*
Other – Date*

MM slash DD slash YYYY
Pap Smear Medical History
When was your last pap smear (month and year ) ?*

MM slash DD slash YYYY
- Normal
- Abnormal
When was your last abnormal pap smear?
Have you undergone any procedures as a result of an abnormal pap smear?
- Yes
- No
Yes (check all that apply)
- Colposcopy
- Cryosurgery (Freezing)
- Laser treatment
- Conization
- Leep procedure
Breast Screening History
Have you ever had a mammogram?
- Yes
- No
Date

MM slash DD slash YYYY
Result
- Normal
- Abnormal
Do you perform self breast exams?*
- Yes
- No
Medical History
Are you allergic to any medications?
- Yes
- No
Please list and describe reactions*
Are you allergic to any foods (peanuts, eggs, etc.)?
- Yes
- No
Please list and describe reactions*
Do you take any medication?
- Yes
- No
If yes, please list*
Do you take any herbal medicines/vitamins or health food store supplements?
- Yes
- No
Please list*
Do you have any medical problem(s)?
- Yes
- No
Please list type, dates, and treatments.*
Social History
How many caffeinated beverages (coffee, tea, soda) do you drink per day?
Do you smoke cigarettes?
- Yes
- No
How many/day?
Quit – when?
Do you drink alcohol?
- Yes
- No
Surgical History
Have you had any surgeries?
- Yes
- No
Number of surgeries

Year	Type of surgery in chronological

Did you have any anesthesia problems?
- Yes
- No
Describe
Physical Symptoms
None of these Issues
- None of these Issues
General
- Diabetes
- Hair loss
- Anorexia/Bulimia
- Lack of energy
- Fever/chills
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Head, Eyes, Ears, Nose, and Throat
- Dizziness
- Loss of sense of smell
- Headaches
- Chronic nasal congestion
- Blurred vision
- Ringing ears
- Hearing loss/deafness
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Respiratory
- Shortness of breath
- Asthma
- Bronchitis
- Pneumonia
- Tuberculosis
- Bloody cough
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Endocrine/Hormonal
- Recent weight gain or loss
- Thyroid gland problems
- Rapid weight gain or loss
- Excessive hunger/thirst
- Temperature intolerance-hot flashes or feeling cold
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Breasts
- Discharge
- Lumps
- Abnormal mammogram
- Reduction
- Augmentation/Breast Implants
- Other
- None
Describe so it’s consistent with the others
- Saline
- silicone
Describe so it’s consistent with the others – do for all similar responses
Neurological Problems
- Weakness/Loss of balance
- Seizures/Epilepsy
- Headaches
- Migraine headaches
- Numbness
- Memory Loss
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Gastrointestinal
- Nausea/Vomiting
- Ulcers
- Hepatitis
- Diarrhea
- Blood in your stools
- Irritable Bowel Syndrome
- Change in bowel habits
- Colitis (ulcerative or Cohn’s)
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Genito-Urinary
- Bladder infections
- Kidney infections
- Vaginal infections
- Frequent urination
- Blood in the urine
- Leaking Urine
- Herpes
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Skin/Extremities
- Unexplained rash/inflammation
- Acne
- Skin caner
- Burn injury
- Moles changing in appearance
- Excess hair growth
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Musculoskeletal
- Unusual muscle weakness
- Decreased energy/stamina
- Rheumatoid arthritis
- Lupus Erythematosus
- Myasthenia gravis
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Hematologic
- Blood clotting disorder/Blood clot
- Sickle Cell Anemia
- Thrombophlebitis
- Easy bruising
- Swollen glands/lymph nodes
- Blood transfusions
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Cardiovascular
- Palpitations/Skipped beats
- Chest pain
- Heart attack
- Stroke
- Murmurs
- High blood pressure
- Rheumatic fever
- Mitral valve prolapse
- Other
- None
Do you need antibiotics before dental procedures?
- Yes
- No
Describe so it’s consistent with the others – do for all similar responses
Mental Health Problems
- Depression
- Anxiety disorder
- Schizophrenia
- Other
- None
Describe so it’s consistent with the others – do for all similar responses
Disorders in Your Family
Breast cancer
- Yes
- No
- Don’t Know
If yes, please list relationship to you*
Ovarian cancer
- Yes
- No
- Don’t Know
If yes, please list relationship to you*
Other cancer
- Yes
- No
- Don’t Know
If yes, please list relationship to you*
PRIOR INFERTILITY TESTING AND TREATMENT
*Have you had prior infertility testing or treatment elsewhere?-Partner
- Yes
- No
Prior Tests (check all that apply):*
- Thyroid test
- Ovulation test
- Day 3 blood test for FSH level
- Hysterosalpingogram (HSG)
- Laparoscopy
- Hysteroscopy surgery
- Progesterone blood test
- None of these
Thyroid test
Date*

DD slash MM slash YYYY
Results*
Ovulation test
Date*

DD slash MM slash YYYY
Results*
Day 3 blood test for FSH level
Date*

DD slash MM slash YYYY
Results*
Hysterosalpingogram (HSG)
Date*

DD slash MM slash YYYY
Results*
Laparoscopy
Date*

DD slash MM slash YYYY
Results*
Hysteroscopy surgery
Date*

DD slash MM slash YYYY
Results*
Progesterone blood test
Date*

DD slash MM slash YYYY
Results*
Prior Treatment (Check all that apply):*
- Intrauterine insemination
- Clomiphene citrate with timed intercourse
- Clomiphene citrate with insemination
- Daily fertility drug injections with insemination
- Completed in vitro fertilization cycle(s)
- Frozen embryo transfers
- None of these
Intrauterine insemination
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Clomiphene citrate with timed intercourse
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Clomiphene citrate with insemination
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Daily fertility drug injections with insemination
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

Completed in vitro fertilization cycle(s)
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

# of eggs	# of embryos transferred	# frozen

Frozen embryo transfers
No. of cycles*

List*

Dates (MM/YY to MM/YY)	Outcome

# of eggs	# of embryos transferred	# frozen

Cancelledin vitro fertilization attempt(s): # of cycles*
Any other prior treatment (describe)
* Additional Information/Complications:
FEMALE PARTNER'S SIGNATURE*
Date (Female Partner)*

MM slash DD slash YYYY
List current medications
List any current medical problem(s)
How many caffeinated beverages (coffee, tea, soda) do you drink per day?
Do you smoke cigarettes?
- Yes
- No
- Quit
How many/day?
How many years ?
When
Do you drink alcohol?
- Yes
- No
Liquor*
- Beer
- Wine
- Liquor
Per week*
Do you use marijuana, cocaine, or any other similar drug?
- Yes
- No
Describe
Do you exercise?
- Yes
- No
Describe
Physician Notes (for office use only)
Have you been evaluated by a urologist?
- Yes
- No
Have you previously conceived with another woman?
- Yes
- No
How many times?
Birth control used?
- Yes
- No
Have you had a semen analysis?
- Yes
- No
Do you have difficulty with erections?
- Yes
- No
Do you have retrograde ejaculation of sperm into the bladder?
- Yes
- No
Have you had any of the following sexually transmitted diseases or pelvic infections?
- Yes
- No
Check all that apply
- Chlamydia
- Gonorrhea
- Herpes
- Genital warts/HPV
- Syphilis
- HIV/AIDS
- Hepatitis
- Other
Other
Any medications?
Have you had a vasectomy?
- Yes
- No
Date*

MM slash DD slash YYYY
Have you had a vasectomy reversal?
- Yes
- No
Date*

MM slash DD slash YYYY
Have you had surgery for varicocele repair?
- Yes
- No
Date*

MM slash DD slash YYYY
Have you had hernia surgery?
- Yes
- No
Date*

MM slash DD slash YYYY
Did you undergo any bladder or penis surgery as a child?
- Yes
- No
Date*

MM slash DD slash YYYY
Have you had chemotherapy for cancer?
- Yes
- No
Date*

MM slash DD slash YYYY
You allergic to any medications?
- Yes
- No
Date*

MM slash DD slash YYYY
Please list and describe reactions
SPOUSE/MALE PARTNER'S SIGNATURE*
Date(Male Partner)*

MM slash DD slash YYYY
Physician Notes (for office use only)
I confirm that I have reviewed the information above

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Email Consent
Patient Name*
Patient E-mail Address:*
RISK OF USING EMAIL
Coastal Fertility Medical Center (CFMC) offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patients should consider before using e-mail. These include, but are not limited to, the following risks:
- E-mail can be circulated, forwarded, and stored in numerous paper and electronic files.
- E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients.
- E-mail senders can easily misaddress an email.
- Email is easier to falsify than handwritten or signed documents.
- Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
- Employers and online services have a right to archive and inspect e-mails transmitted through their systems,
- E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
- E-mail can be used to introduce viruses into computer systems.
- E-mail can be used as evidence in court
CONDITION FOR THE USE OF E-MAIL
CFMC will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, CFMC cannot guarantee the security and confidentiality of e-mail communication and will not e liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Thus, patients must provude written consent, except as authorized or required by law.
Consent to the use of e-mail for patient information. Consent to the use of E-mail includes agreement with the following conditions:
- All e-mails to or from the patient concerning diagnosis or treatment will be printed out and made part of the patient’s medical record. Because they are a part of the medical record, other individuals, authorized to access the medical record, such As staff and billing personnel, will have access to those e-mails.
- Your Provider may forward e-mails internally to CFMC staff and agents as necessary for diagnosis, treatment, reimbursement, health care operations, and other handling .Your Provider will not, however forward e-mails to independent third parties without the patient’ s prior written Consent, except as authorized or required by law.
- Although CFMC staff will endeavor to read and respond Promptly to an e-mail from the patient, we cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus the patient shall not use e-mail for medical emergencies or other time-sensitive matters.
- If the patients e-mail requires or invites a response from Provider and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond.
- The patient should not use e-mail for communicationregarding sensitive medical information such as information regarding sexually transmitted diseases, AIDS/HIV, mental Health, developmental disability, substance abuse.
- The patient is responsible for informing your provider of any type of information the patient does not want to be sent by e-mail, in addition to those set out in 2(e) above
- The patient is responsible for protecting his/her pass word or other means of access to e-mail. CFMC is not liable for breaches of confidentiality caused by the patient or any third party.
- CFMC Providers shall not engage in e-mail communication that is unlawful, such as unlawful practicing medicine across state lines.
- It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.
INSTRUCTIONS
To communicate by e-mail, the patient shall:
- Limit or avoid use of his/her employer’s computer.
- Inform CFMC of changes in his/her e-mail address.
- Put the patient’s name in the body if the e-mail.
- Include the category of the communication in the e.mail’s subject line, for routing purposes (e.g., billing question).
- Review the e-mail to make sure it is clear and that all relevant information is provided before sending to your Provider.
- Inform your Provider that the patient received an email from your Provider.
- Take precautions to preserve the confidentiality of e-mails, such as using screen savers and safeguarding his/her computer password.
- Withdraw consent only by e-mail or written communication to your Provider.
PATIENT ACKNOWLEDGMENT AND AGREEMENT
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between CFMC staff and me, and consent to the conditions outlined herein, as well as any other instructions that Provider may impose to communicate with patients by e-mail. Any questions I may have had were answered.
Patient signature*
Date(Patient)*

MM slash DD slash YYYY
Thank you for taking the time to make this all. When you come in for your consultation, you will meet with a financial advisor who will compare notes with your research and the verification that took place in our office. If three are any discrepancies, another call will be made by our staff to give us an accurate picture of what your insurance covers.

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ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE AND ACKNOWLEDGMENT OF MEDICAL BOARD OF CALIFORNIA NOTICE TO CONSUMERS
I acknowledge that I have read the Privacy Notice
Patient or Personal Representative*
Date*

MM slash DD slash YYYY
If Personal Representative’s signature appears above, please describe Personal Representative’s relationship to the patient.
Patient's signature*
Partner's signature*
Date(Patient)*

MM slash DD slash YYYY
Date(Partner)*

MM slash DD slash YYYY
I HAVE READ AND AGREE TO THE FINANCIAL POLICIES ENCLOSED*
- I HAVE READ AND AGREE TO THE FINANCIAL POLICIES ENCLOSED

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Credit Card Authorization Agreement Form
I/We,
Name*
Other Name
authorize Coastal Fertility Medical Center to use the below credit card for services rendered. I understand that all fees for services rendered need to be paid at the time of the visit or prior to the service performed. In the event that
additional services/fees are required, Coastal Fertility Medical Center will notify us of any charges due prior to charging our card.
Account/Chart Number (If known):
Card holder's name as it appears on card:*
Type of Card:*
- Visa
- MasterCard
- AMEX
- Discover
Credit Card Number:*
Security Code:*
Expiration Date:*
Billing Address:
STORAGE PATIENTS
PLEASE USE THIS CREDIT CARD FOR MY ANNUAL STORAGE BILLING.
- PLEASE USE THIS CREDIT CARD FOR MY ANNUAL STORAGE BILLING.
*if this is checked we will automatically charge your credit card for your annual storage fees*
OTHER ACCOUNT BALANCES
PLEASE CHECK HERE IF AUTHORIZING A ONE TIME PAYMENT
- PLEASE CHECK HERE IF AUTHORIZING A ONE TIME PAYMENT
Amount:*
PLEASE CHECK HERE IF YOU WISH TO KEEP YOUR CARD ON FILE FOR FUTURE PAYMENTS
- PLEASE CHECK HERE IF YOU WISH TO KEEP YOUR CARD ON FILE FOR FUTURE PAYMENTS
Special Instructions (i.e. split payment?)*
Card Holder's Signature*
Date

MM slash DD slash YYYY
Print Name:
Patient Signature (If different from Card Holder)*
Date

MM slash DD slash YYYY
*Please note: All credit card information is kept confidential. Every effort will be used to keep this and all confidential information secure. Thank you.additional services/fees are required, Coastal Fertility Medical Center will notify us of any charges due prior to charging our card.
Name

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

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NP Infertility History Form A(M-F) *

Family Genetic History Quest *

Permission to Verify Insurance*

Insurance Verification Sheet *

Medical Record Request *

Halloween 2019

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LGBT friendly

Our fertility clinic focuses on helping you build your family regardless of your sexual orientation or the gender you choose to identify with. We are even taking further steps to make LGTB people feel more welcome at our fertility clinic. Each of our patient-facing staff goes through LGTB training to let family-building clinicians provide necessary support and make you feel highly welcome.

Financial Transparency

Coastal Fertility Medical Center offers one of the most advanced fertility treatments and is completely transparent regarding the costs of procedures and any other expenses that you may have to pay before commencing your treatment. This differentiates us from some fertility clinics that reduce prices before the signing of the contract but charge you extra later on. We make sure our patients are well aware of any possible extra pricing that may occur over the course of their treatment.

A One-stop Model

The infertility industry is currently segmented, with each service or treatment being handled by a different provider. Our all-inclusive model simplifies an otherwise complex and difficult process. We are here to revolutionize the infertility industry by offering a one-stop-service model to assist our patients through infertility challenges while reducing physical, emotional, and financial risks.

Superior Expertise

Our globally respected team of specialists are helping improve IVF technologies to enter into a generation of better outcomes for infertility. Although you’ll have a doctor guiding you, you are also going to benefit from the experience and insights of other doctors during case review collaboration meetings, which take place every week. So, you won’t just rely on the expertise of a specialist but benefit from the knowledge of many reputed fertility experts.

Specialized in Difficult Cases

Our team specializes in difficult cases and help patients who may have been considered “hopeless” at other fertility clinics. Thanks to our personalized solutions, expertise, and internal collaboration, weare able to maximize pregnancy success rates that are well above the industry average, even in difficult infertility cases.

Personalized Solutions

We know that every situation is different and that everyone requires different treatments. Unlike facilities that take “a one-size-fits-all” approach for all cases, our fertility specialists use more than 40 customized protocols to raise the chances of success. The customized approach even extends to our fertility laboratory. Our on-site lab director and his highly-experienced team nurture every embryo and egg to increase the odds of success of each cycle.

Financial Transparency

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CONTACT INFORMATION

PATIENT MEDICAL HISTORY AND INFORMATION

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Credit Card Authorization Agreement Form

NP Contact information form *

NP Infertility History Form A(M-F) *

Family Genetic History Quest *

Permission to Verify Insurance*

Insurance Verification Sheet *

Email Consent*

Privacy Notice*

Medical Record Request *

Halloween 2019

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