Forms & Instructions

There are several forms that you will need to complete prior to fertility evaluation appointment. These forms help us to better understand your medical history and provide you with an individualized treatment plan. Please review the appropriate forms below and bring the requested form(s) with you to your first appointment.

To obtain a copy of your medical records, please see the medical record release form.

New Infertility Patients

• New patient history form - This form is a detailed medical history for both the female and male partner. Fully completing the form will allow our doctors to have a deeper understanding of your medical history and better enable them to form a comprehensive plan for your fertility treatment.
• Billing and Collections Policy - This is a form that explains our billing policy. We ask that you read it and sign it.
• ASRM Genetic Screening Handout – This is a informational handout from American Society for Reproductive Medicine that the recommendation to perform genetic screenings to prevent birth defects.
• Preconception Counseling Information - This is a questionnaire which will help our doctor understand your genetic background and make proper recommendations as to any genetic screening that might be recommended for you.
• Genetic Screening - Another document that helps you further understand the benefit of genetic screening before conceiving a child/(children). Genetic screening is recommended for almost all patients. The genetic screening that is recommended is dependent on your ethnic group.
• Estimated Costs - This document details some of the costs that you mind face in your fertility treatment. We provide this so that you have an idea of what certain procedures cost and what you can expect to pay. These are average costs and may vary from patient to patient.
• Registration Form - This form is where you will enter demographic information for you and your partner. This includes insurance information and emergency contact information.
• Pregnancy Considerations - This document contains some common concerns/issues that you might want to consider before becoming pregnant, such as exercise, caffeine use, mammograms, vaccinations, etc.
• Patient Phone Guide - We do our best to answer your calls and emails whenever you are trying to get in touch with us. This phone guide will help you call the correct number the first time, and hopefully avoid transferring you around to the right person.
• Insurance Coverage - This is a questionnaire that we would like you to fill out. It will help our providers be aware what fertility benefits you have so that we can consider all options to be as cost effective as possible as we plan your fertility care.
• PHI Authorization for Specialized Care - This form allows us to included your protected health information in the medical record of another individual such as a spouse or partner, as it relates to your fertility treatment and care. Each party must fill out individual forms. Please fill this out and bring with you to your visit.

IVF Patient Forms

IVF Packet: Below are the documents that we give to all our patients going through IVF at UCRM. Please review each section, feel free to print out sections that you feel are important or would like to save. We do ask that all our patients review all the paperwork and print, fill out and bring pages 5-6 of section 1 and page 20 from section 2 when they come to their appointment.

• Section 1 - Intro, registration, and questions.
• Section 2 - Preparing for your IVF cycle. This sections contains information on how to contact us, what to expect, and guidelines we have regarding IVF, genetic screening and counseling.
• Section 3 - Consent Forms. You will receive this at your appointments.
• Section 4 - Financial information. This section contains information such as the costs of IVF, medications, financing options, and payment agreement.
• Section 5 - Additional Resources. This section contains referral information for a psychologist, a letter regarding acupuncture, and some web resources you might find helpful.

• Payment Agreement - Please bring this with you when you pay for your IVF cycle.

New GYN Patients

• Billing and Collections Policy - This is a form that explains our billing policy. We ask that you read it and sign it.
• Registration Form - This form is where you will enter demographic information for you and your partner. This includes insurance information and emergency contact information.
• Insurance Coverage - This is a questionnaire that we would like you to fill out. It will help our providers be aware what fertility benefits you have so that we can consider all options to be as cost effective as possible as we plan your fertility care.
• Gynecological New Patient History Form - This form is a detailed medical history for both the female and male partner. Fully completing the form will allow our doctors to have a deeper understanding of your medical history and better enable them to form a comprehensive plan for you.

Pelvic Pain Patients

• Pelvic Pain Assessment Form - This is a questionnaire that will help your physician understand your specific issues and make proper recommendations and treatment plans in the course of your care

Medicial Release Forms

• Medical Record Release Form - We ask for 10-14 business days once we receive your notarized/signed authorization. This form needs to be notarized or signed in front of (witnessed by) one of our staff members. You can bring it to us in person, email back to us at fertilitydr@hsc.utah.edu, or fax it to us at 801-585-2388.