Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Fertility Clinic Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Partner Information
Duration of Infertility
Pregnancy History
Menstrual Cycle Documentation
Additional details
Prior Fertility Treatments
Prior Fertility Test Results
Ovarian Reserve Testing
Gynecologic Surgical History
Endocrine Screening History
Male Partner Reproductive History
Semen Analysis Results
Lifestyle & Environmental Factors
Additional details
Current Medications & Supplements
| Medication | Dose | How often |
|---|---|---|
Psychosocial Screening
Family Building Goals
Insurance & Fertility Coverage
Please bring to your visit: prior records
Consent & Signature
Date
Fertility Clinic Intake Form template from formisoft.com. formisoft.com/intake-templates/fertility-intake