Parents expecting a child

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

  • UCRM new patient questionnarie 2013 - 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.

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.
  • 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
  • Billing and Collections Policy - This is a form that explains our billing policy. We ask that you read it and sign it.

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.

Reproductive Medicine services are available at the Utah Center for Reproductive Medicine as well as multiple locations through out the state of Utah, including Centerville, Orem, South Jordan and Park City. Our reproductive endocrinologists offer a wide range of services including:

  • Infertility counseling
  • Infertility monitoring and treatment
  • IUD insertion and removal
  • Annual gynecological exams
  • Endocrinology
  • Diagnosis and treatment of polycystic ovary syndrome
  • In vitro fertilization
  • Treatment of endometriosis
  • Pediatric and adolescent gynecology services

Our highly trained reproductive endocrinology specialists are experts in both the treatment and research of infertility and our clinic consistently boasts one of the highest success rates in the nation.

Neighborhood Health Center Locations:

Utah Center for Reproductive Medicine 675 Arapeen Way, Suite 205
Salt Lake City, Utah 84108-1237
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University of Utah Health Care
Centerville Health Center
26 South Main
Centerville, Utah 84014
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Dixie Regional Medical Center 544 South 300 East
St. George, UT 84770
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McKay Dee Hospital 4401 Harrison Blvd.
Ogden, UT 84403
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University of Utah Health Care
Redstone Health Center
1743 W. Redstone Center Drive, #115
Park City, Utah 84098
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University of Utah Health Care
South Jordan Health Center
5126 W. Daybreak Parkway
South Jordan, 84095
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Utah Valley Regional Medical Center
Woman’s and Children’s Clinic
1034 N 500 W
Provo, Utah 84604