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
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