New Patient Forms

Please contact the office for DocuSign forms

Gynecology New Patient Forms 

These forms should ONLY be used for appointments with Tara Busset, CRNP

Gynecology Patient Intake Form

Gynecology Patient Consents

Gynecology Medical History Form

  • You should  print, complete and sign the forms and bring to your first appointment

IVF Orientation Forms

IVF orientation form must be completed by all IVF patients and Biopsy for PGT should be completed by all IVF patients considering PGT as well.

IVF Consents

The below IVF consents are available via e-sign. If you are not able to utilize e-sign for these documents, all forms must then be completed, notarized* and returned to the IVF staff prior to an IVF cycle start. *If it is not possible to have the consents notarized they must be signed by both parties in the presence of a Main Line Fertility employee after presenting photo ID prior to an IVF cycle start.

Record Request Forms

Record Requests take 7-10 business days to process from the time of receipt.

For an e-sign version of the record request, please contact [email protected]

Please send your completed forms to [email protected] or via fax to your primary office location.

Once all applicable forms are completed, please print and sign the forms, save as your first and last name and email to [email protected] 

PLEASE NOTE: Any forms, medical records, results etc. above must be emailed in .pdf format. No .jpeg or photos are permitted, and the scanned pages must not be reduced in size.
Correspondence can also be sent via regular mail to our main office address ATTN: Patient Forms. It is recommended that you mail it via a trackable mail service as these forms contain identifying information. This will also ensure that your forms are received by our office.