Egg Freezing Fertility Preservation Patient Intake Form

Items you will need to complete this form

  • Photos or scanned copies of the front and back of your driver’s license or other ID card.
  • Photos or scanned copies of the front and back of your health insurance ID card(s).
  • A list of your current medications.
  • A list of your health history, including past fertility testing and treatments.

Tips for using this form

  • This form takes about 30 minutes to complete. We recommend having all materials ready before starting this form.
  • Ensure any images are saved on your computer or phone before uploading them to this form. If they are not saved, you may receive an error message.
  • Upload images that are 5 MB or smaller in size. Large images may prevent you from being able to complete the form.
  • Complete the form when you have a stable internet connection. Weak connections may cause problems with saving or submitting the form.
  • Use the most up-to-date version of your web browser. For best form performance, we recommend using either Firefox or Chrome.
  • Enable Javascript and cookies in your browser.

Our commitment to patient security and privacy

We understand that this form contains a large amount of highly personal, sensitive information. We are dedicated to ensuring your privacy and use an online form that is fully encrypted. All of your personal information is stored in an encrypted database and is only accessed by our medical team and staff. We ask for personal details, such as medical history, insurance information and proof of identity, to ensure we can provide you with the highest level of care.

Thank you for completing your egg freezing  fertility preservation form! We look forward to seeing you soon.

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