Patient Intake & Health History Form

If you are a new patient who is interested in fertility treatment with RSC and have completed steps 1 and 2, please continue to step 3 and submit the new patient paperwork below (also available in Español and 中文).


If you are a monitoring, fertility check or semen analysis patient, please do not complete the form below.

Step 3: Please complete the following form. If you have any questions, please contact our office:
(888) 377-4483

Available in Español and 中文.

Items you will need to complete this form

  • A list of
    • Your current medications.
    • Your partner’s current medications.
    • Your health history and a list of immediate family members (parents or siblings) with a history of cancer or any known genetic diseases.
    • Your partner’s health history and a list of your partner’s immediate family members (parents or siblings) with a history of cancer or any known genetic diseases.

Tips for using this form

  • We recommend having all materials noted above ready before starting this 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.
  • Did you receive an error or have to stop your form before it was fully completed? Please contact RSC to discuss next steps.

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 new patient paperwork! We look forward to seeing you soon.