Every patient who comes to RMA Southern California for fertility care must complete and submit a medical intake form. This medical history will allow your physicians and care team to make the most accurate assessments possible concerning your fertility status, and this helps them devise the most effective treatment plans possible. Select the intake form that most appropriately describes you as a patient. Couples seeking services will need to complete patient intake forms for each partner.
Please review and complete the appropriate forms, then return them to our office one to two weeks prior to your first appointment. You may fax them to our office or drop them off in-person.
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.
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.
This form collects your basic demographic information. It should take five to ten minutes to complete.
SUMMARY HISTORY FORM
This form collects your infertility history. It should take five to ten minutes to complete.
FERTILITY PRESERVATION INTAKE FORM (ONCOLOGY PATIENTS ONLY)
This is the FPC Intake Form. It should take five to ten minutes to complete.
TRANSGENDER INTAKE FORM
This is the Transgender Intake Form. It should take five to ten minutes to complete.
Please click below to download the provided medical record release and send it to your previous fertility care provider, OB/GYN, urologist, or other medical provider to request your medical records.
It’s vital for us to receive a copy of your records one to two weeks before your new patient consultation. You can fax them to our office or drop them off in-person at your convenience. You can also contact our patient liaison team if you’d like to submit them electronically to our secure email address.
MEDICAL RELEASE FORM
Reproductive Medicine Associates of Southern California understands and acknowledges the need for our patients to have access to their personal medical records. Medical release authorization forms can be accessed and downloaded below. Depending on how you are submitting your request for medical records, please allow at least 1-2 weeks of processing time. Digital delivery like email or fax may take the shortest time, compared to hard copy requests that need to be mailed.
Completed medical release forms may be faxed to 424.293.8842 or dropped off in person.
MEDICAL RECORD RELEASE FORM
MENTAL HEALTH CARE AUTHORIZATION FORM
These additional forms will be provided to you upon arrival at your new patient appointment. To assist in the efficiency during registration, you may elect to complete these forms below in advance.
Please complete all forms and return them to our office 1-2 weeks before your new patient appointment.
EMAIL CONSENT FORM
PATIENT PRIVACY FORM
OUTSIDE REFERRAL FORM
PATIENT NON-DISCRIMINATION POLICY
One of the most stressful parts of receiving fertility care is often waiting for an appointment. We ask you to be considerate of other patients who are waiting for an appointment at RMA Southern California by reviewing our guidelines concerning cancellations and rescheduling. If you have any questions about these policies, please contact our patient liaison department. Please remember that we require at least 48 hour notice if you must cancel your appointment. We’ll use this time to contact our other patients who may be able to take advantage of your appointment time. Please note that if you miss a visit at RMA Southern California without contacting us, we will bill you for the visit.
CANCELLATION RESCHEDULE POLICY
After three appointment cancellations, RMA Southern California will request that you complete a Credit Card Authorization Form for payment. This helps us ensure your commitment to your next rescheduled visit. You will be charged for the initial consultation fee, and after your consultation we will reimburse this fee minus your copay.