IVF New England Patient Forms

Forms you may need related to your assisted reproduction care at IVF 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.


To Request Your IVF New England 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: IVF New England cannot release records sent to IVFNE from another doctor’s office.

8. Medical Record Request Form

9. Rhode Island Patients Medical Record Request Form

If you are being discharged from IVF New England 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 IVFNE 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.

10. OB Medical Record Request
 

IVF New England Patient Forms
New England's award-winning service helping gay, lesbian, and transgender people become parents.