RSC New England Patient Forms
Forms you may need related to your assisted reproduction care at RSC New England
Billing
Recurring Credit Card Billing for Cryopreserved Specimens
Cryobiology Forms
1. Consent to Discard Sperm or Testicular Tissue
2. Consent to Discard Cryopreserved Embryos
3. Consent to Release Cryopreserved Sperm [to patient's custody, patient's representative/agent/designated facility]; This consent requires that the patient contact the Cryobiology Program to make arrangements.
4. Consent to Release Cryopreserved Embryos [to patient's custody, patient's representative/agent/designated facility or research]; This consent requires that the patient contact the Cryobiology Program to make arrangements.
5. Receipt of Cryopreserved Sperm
6. Receipt of Cryopreserved Embryos
7. Donor Sperm Acquisition Form
IVF Consent
IVF Consent Form
Assisted Reproduction Consent for Treatment Guide Book
New patients who may need to consider in vitro fertilization (IVF) should read this booklet, which provides information about IVF and related procedures. It is essential to review this information in preparation for your consent for treatment.
Patient Questionnaires
Patient questionnaires must be filled out completely and mailed or faxed to RSC Lexington headquarters (1 Forbes Road, Lexington, MA 02421, Fax (781) 674-1520) to arrive at least one week prior to your scheduled appointment. Questionnaires must be mailed to Lexington even though you may be seeing your physician at a satellite office (e.g.. Bedford, NH; Cambridge or Westborough, MA, etc.)
EXCEPTION: If you are being seen at the Rhode Island office, please mail or fax your questionnaires to Rhode Island (134 Thurbers Avenue, Suite 207, Providence, RI 02905, Fax (401) 861-6066).
8. Female and Male Patient Questionnaires
To Send Your Medical Records to RSC
Sign the Medical Record Release Form and send it to your Primary Care Physician, OB/GYN, Urologist or other doctor and ask that doctor's office to send your medical records to the Reproductive Science Center in Lexington, Massachusetts.(If you are being seen at the Providence, RI office, please ask your doctor to send the form to Rhode Island.)
9. Medical Release Form, Send to Lexington
10. Medical Release Form, Send to Rhode Island
To Request Your RSC Medical Record
To request a copy (or copies*) of your medical record please complete the attached form and include the required information. Medical records are mailed to a patient within ten (10) business days from the date of receipt of this completed request form. The first copy of a patient’s medical record is released free of charge. * A fee of 25 cents per page, payable in advance, is charged for additional copies. It is recommended that patients have their medical record sent to their address and make any additional copies as needed for your physicians. Note: RSC cannot release records sent to RSC from another doctor’s office.
11. Medical Record Request Form
12. Rhode Island Patients Medical Record Request Form
If you are being discharged from RSC to your obstetrician (OB) for pre-natal care we will automatically send a copy of your obstetrical ultrasound report, a letter outlining your treatment at RSC and your Patient Checklist to your OB. Some OBs may also want copies of your infectious disease and genetic test results. To request copies of these additional records please fill out the OB Medical Record Release Form below and fax it to our Medical Records Department at 781 674-1520.
