keyboard_arrow_downEach patient who visits RMANJ 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 a 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.
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.
FPC 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.
MEDICAL RECORD AUTHORIZATION FORM
This is the Medical Records Authorization Form. It should take five to ten minutes to complete.
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
Click here to download the form.
PATIENT PRIVACY FORM
Click here to download the form.
OUTSIDE REFERRAL FORM
Click here to complete the form.
AUTHORIZATION FOR RELEASE OF PREGNANCY DISCHARGE RECORDS
Click here to download the form.
CREDIT CARD AUTHORIZATION FORM
Click here to complete the form.
COMMUNICATION FORM
Click here to complete the form.
FINANCIAL POLICY FORM
Please complete the provided medical record release and send to your OB/GYN, urologist, previous fertility center or other medical provider to request your medical records.
We request a copy of your previous medical records to be forwarded to our office 1-2 weeks before your new patient appointment.
MEDICAL RECORD RELEASE FORM
Click here to download the form.
UROLOGY MEDICAL RELEASE FORM
Reproductive Medicine Associates of New Jersey (RMANJ) 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 973-290-8370 or dropped off in person at any RMANJ location.
MEDICAL RELEASE AUTHORIZATION FORM
Click here to download the form.
MENTAL HEALTH CARE AUTHORIZATION
CANCELLATION POLICY
As you know, waiting for an appointment to begin fertility treatment can be stressful, so we ask you to be considerate of other patients who are waiting for their appointment with RMANJ. To ensure every patient is satisfied, here at RMANJ, we have developed guidelines for canceling and rescheduling new patient appointments. Please review the following and call the patient liaison department at 973-656-2089 with any questions: If it becomes necessary for you to cancel your appointment, we require at least 72 hour notice, so that we can contact other patients who may be able to take your scheduled appointment. If you do not contact us, RMANJ can bill you for the missed visit.
CANCELLATION RESCHEDULE POLICY
If you have cancelled or rescheduled your appointment under 72 hours, RMANJ will ask you to complete a Credit Card Authorization Form for payment. This will ensure us of your commitment to your next rescheduled visit. You will be charged $250.00 fee for the initial consultation fee and when you come in for your consultation, you will be reimbursed this fee minus your co-pay.
Click here to download the form.
CREDIT CARD AUTHORIZATION FORM
Click here to complete the form.
CHILDREN IN WAITING ROOM POLICY
Click here to download the form.
HIPAA PRIVACY POLICY
Click here to download the form.
PACU VISITATION POLICY
Click here to download the form.
POLICY REGARDING AGE AND INFERTILITY TREATMENT
