Fertility New Patient Forms

New Patient Checklist

    • For your review

COVID-19 Consent for Care

      • You and your partner (if applicable) should  print, complete and sign the form(s) and bring to your first appointment

Demographic Form

Patient Health History and Consent Forms

 

Carrier Screening Information

    • For your review

Notice of Privacy Practices

    • For your review

Gynecology New Patient Forms

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

Effective Jan 1, 2019, the new IVF consents must 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

Please send your completed forms to forms@mainlinefertility.com or via fax to your primary office location.

Please note – we cannot accept typed signatures. Patients must print and sign. For an e-sign version of the record request, please contact  support@mainlinefertility.com. Record requests take 7-10 business days to complete.