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We have posted several of our practice forms for patients' convenience. Many are available in both Word and PDF format. If you are interested in making an appointment please see our "New Appointments" page.
1. Introduction to RCC Letter:
Introduction RCC Letter
v4 (.pdf)
2. Patient Registration Form:
Registration Form (.pdf format)
;
Registration Form
Digital v3
3. Medical Information Questionnaire that has questions for both the husband and the wife.
Digital
Format (preferred):
Medical History Form V6 (Word Digital format);
PDF Format:
Medical History Form v13
4. Patient portal (preferred secure method for
information entry):
https://secure.fertilitydr.com/patient/
Enter information into the patient portal (highly preferred
method - see : http://www.fertilitydr.com/new-appointments.html)
or download the appropriate files, please print and fill-in all fields. FAX (801-878-8890) or mail the completed forms to our office in order for it to arrive at least 3 days prior to your scheduled initial consultation. A digital registration
and history form is also available (preferred format) for electronic completion.
The completed forms can be sent back electronically to info@FertilityDr.com and signed during the appointment.
If you have consulted with other physicians or practices regarding your infertility, please request that copies of your records be sent in advance. Specifically request any previously completed hormonal testing (such as Prolactin, TSH, day 3 FSH and day 3 estradiol, day 10 FSH, testosterone, DHEAS, fasting glucose, or fasting insulin levels), Clomiphene Citrate Challenge test (CCCT), a saline sonogram (hysterosonogram), hysterosalpingogram (HSG), laparoscopic or hysteroscopic surgery or semen analysis. Request that copies of the reports and actual films from any x-rays be sent for review. Records regarding any treatment such as clomiphene citrate, gonadotropin (FSH) injections, intrauterine insemination (IUI) or in vitro fertilization (IVF) should also be obtained.
Completing the registration form, questionnaire and obtaining all pertinent medical records in advance will allow our physicians to have access to all your records prior to your arrival. This will enable us to provide the best advice possible for your particular medical situation during your initial consultation. For financial information regarding the initial consult see: pricing
Patient Satisfaction Questionnaires
Your feedback is important to us. Please
complete the questionnaire for your primary RCC physician by
clicking on the link below.
If you have recently completed an initial
consult with one of our physicians please complete the
following:
1. Dr Keith L. Blauer:
http://survey2.9gs.org/survey.php?code=v2qct7b
2. Dr. James S. Heiner:
http://survey2.9gs.org/survey.php?code=d6kfq09
If you have recently completed an IVF cycle with one of our
physicians please complete the
following:
1. Dr Keith L. Blauer:
http://survey2.9gs.org/survey.php?code=0g5ykhk
2. Dr. James S. Heiner:
http://survey2.9gs.org/survey.php?code=sqaz8uc
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