Infertility / IVF Intake Form
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Infertility / IVF Intake Form
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The Infertility / IVF Intake Form is a specialized clinical document designed for reproductive endocrinology and fertility practices to capture the comprehensive medical and reproductive history needed to develop individualized treatment plans. It collects detailed menstrual cycle data, obstetric history including prior pregnancies and outcomes, and a thorough inventory of any previous fertility treatments such as ovulation induction, intrauterine insemination, or prior IVF cycles. This level of detail allows reproductive endocrinologists to assess the full clinical picture before recommending a treatment protocol.
This template includes sections for both patient and partner information, recognizing the importance of male factor evaluation in fertility workups. It captures lifestyle factors that may affect fertility outcomes, genetic history relevant to carrier screening decisions, and fields for uploading key diagnostic results including hormone panels, hysterosalpingography (HSG) imaging, and semen analysis reports. The structured format ensures that no critical data points are missed during the initial consultation, reducing the need for follow-up calls to gather missing information.
Ideal for fertility clinics, reproductive endocrinology practices, and IVF centers, this form supports the complex intake workflow that precedes assisted reproduction cycles. It addresses insurance coverage documentation and treatment consent requirements that are unique to fertility care, helping practices maintain organized patient records from the very first visit through egg retrieval, embryo transfer, and beyond.
What's included
- Patient and partner demographic and contact information
- Detailed menstrual cycle and obstetric history sections
- Previous fertility treatment and reproductive surgery inventory
- Lifestyle, genetic, and medication documentation fields
- Diagnostic result upload sections for labs, imaging, and semen analysis
- Treatment goal setting, insurance coverage, and consent verification
- Consent agreement with e-signature
- Structured medication list with dosage and frequency tracking
Who uses this template
- New patient intake at fertility clinics and reproductive endocrinology practices
- IVF cycle planning with comprehensive reproductive history documentation
- Male and female factor infertility evaluation and workup coordination
- Insurance pre-authorization and treatment consent documentation for assisted reproduction
All form fields
17 fields across 4 pages. Customize any field after signing up.
How to use the Infertility / IVF Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Infertility / IVF 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 Infertility / IVF 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 17 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 Infertility / IVF Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Infertility / IVF 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 17 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 Infertility / IVF 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
Sign up and start customizing the Infertility / IVF Intake Form for your practice. Set up in minutes.
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