Fertility Clinic Intake Form
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Fertility Clinic Intake Form
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The Fertility Clinic Intake Form is purpose-built for reproductive endocrinology and infertility (REI) practices, capturing the detailed reproductive, gynecologic, and andrologic history that fertility specialists need for comprehensive evaluation and treatment planning. This template collects patient demographics alongside a thorough reproductive history including duration of infertility, prior conception attempts (timed intercourse, ovulation induction, intrauterine insemination, in vitro fertilization), pregnancy history with detailed outcomes (live births, miscarriages with gestational age, ectopic pregnancies, stillbirths, terminations), and the results of any prior fertility workup including ovarian reserve testing (AMH, day-3 FSH/estradiol, antral follicle count), hysterosalpingography or saline infusion sonography findings, and semen analysis results.
Designed for reproductive endocrinology practices, IVF centers, fertility preservation programs, and donor/surrogacy coordination clinics, this form includes sections for menstrual cycle documentation (cycle length, regularity, dysmenorrhea, menorrhagia, amenorrhea duration), gynecologic surgical history (laparoscopy, hysteroscopy, myomectomy, tubal surgery, ovarian cystectomy, endometriosis excision), endocrine screening (thyroid function, prolactin, DHEA-S, testosterone, PCOS criteria), male partner reproductive history (prior paternity, varicocele, cryptorchidism, ejaculatory dysfunction, hormonal evaluation, prior semen analyses with morphology assessment using Kruger strict criteria), and lifestyle factors affecting fertility (BMI, smoking, alcohol, caffeine intake, exercise patterns, occupational exposures, recreational drug use).
The psychosocial screening section captures the emotional impact of infertility, prior counseling or support group participation, relationship status, third-party reproduction considerations (donor egg, donor sperm, gestational carrier), and insurance coverage for fertility treatments including state mandate verification. Both partners can complete relevant sections, and the form accommodates same-sex couples and single parents by intended method. All fields are HIPAA-compliant and optimized for the REI workflow. The four-page format allows patients to document their fertility journey comprehensively before the initial consultation, enabling the specialist to identify diagnostic gaps, prioritize the evaluation, and discuss evidence-based treatment options at the first visit.
What's included
- Comprehensive reproductive and pregnancy history
- Menstrual cycle and ovarian reserve documentation
- Prior fertility treatment and test result tracking
- Male partner reproductive history and semen analysis
- Psychosocial screening and family building goals
- HIPAA consent with e-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Reproductive endocrinology and infertility practices
- In vitro fertilization (IVF) and assisted reproduction centers
- Fertility preservation programs for oncology patients
- Donor egg, donor sperm, and gestational carrier coordination
All form fields
22 fields across 4 pages. Customize any field after signing up.
How to use the Fertility Clinic Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Fertility Clinic Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Fertility Clinic Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 22 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Fertility Clinic Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Fertility Clinic Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 22 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Fertility Clinic Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
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