Patient Forms

Each patient who visits RMA is directed to complete and submit a medical intake form. These medical histories allow our physicians to make the most accurate assessments of your fertility status and devise the most appropriate treatment plans. Please select the intake form that most accurately reflects you as a patient. If you are seeking our services as an individual or couple, each partner in the couple must complete his or her own intake form.

Please complete the appropriate forms and return them to our office 1-2 weeks before your new patient appointment.

 

FEMALE INTAKE FORM

This is the Female Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to complete the form

 

MALE INTAKE FORM

This is the Male Intake Form, depending on your health history. It should take you between five to ten minutes to complete.

Click here to complete the form

 

FERTILITY PRESERVATION INTAKE FORM

This is the FPC Intake Form. It should take five to ten minutes to complete.

Click here to complete the form

 

TRANSGENDER INTAKE FORM

This is the Transgender Intake Form. It should take five to ten minutes to complete.

Click here to complete the form

 

DEMOGRAPHIC FORM

This form collects your basic demographic information. It should take five to ten minutes to complete.

Click here to complete the form

 

SUMMARY HISTORY FORM

This form collects your infertility history. It should take five to ten minutes to complete.

Click here to complete the form

 

MEDICAL RECORD AUTHORIZATION FORM

This is the Medical Records Authorization Form. It should take five to ten minutes to complete.

Click here to complete the form

 

ESTATEMENT ENROLLMENT FORM

Click here complete the form

 

PATIENT PRIVACY FORMS (COMPLETE BOTH FORMS)

Click here to complete form #1

Click here to complete form #2

 

OUTSIDE REFERRAL FORM

Click here to complete the form

 

COMMUNICATION FORM

Click here to complete the form (Patient)

Click here to complete the form (Partner)

 

FINANCIAL POLICY FORM

Click here to complete the form

 

OUTSIDE MONITORING PATIENT FORM

Click here to complete the form

 

CREDIT CARD AUTHORIZATION FORM

Click here to complete the form.