“Every person that we came into contact with was kind, friendly and knowledgeable.” — SDFC Patient
Forms and Instructions
Before we schedule your first appointment, we kindly ask that you complete our new patient forms. The forms, which include the Patient Registration, Medical History Form(s), Medical Records Release and the New Patient Insurance Information will provide our practice with the information we need to assist you appropriately.
All forms should be completed and sent to their appropriate destinations prior to your first visit. Please send the Medical Records Release to your previous physician well in advance of your appointment. All other forms should be sent to our center either by Fax (858-794-6360) or by e-mail to our New Patient Coordinator. Thank you.
- Patient Registration: Your name, contact information, referral information, and reason for your visit. Please complete this form and return to SDFC.
- Female Medical History Form: Answer a series of questions about your fertility history, past medical history, social history, and family and genetics history. Please complete this form and return to SDFC.
- Male Medical History Form: Answer a series of questions about your fertility history, past medical history, social history, and family and genetics history. Please complete this form and return to SDFC.
- Medical Records Release: Complete this form and fax or mail it to your previous physician, well in advance of your appointment, so that we can access your prior medical records and history.
- Financial Agreement and Insurance Information: Please complete this form and return to SDFC to receive your verification of benefits (VOB). Please complete all fields and include a copy of your insurance card (front and back).
- Notice of Privacy Practices – Information regarding your privacy and protection of health information. Please sign this form and return to SDFC.
- Zika Virus Information Sheet – Zika Virus information and recommendations. Please review travel restrictions, sign this form and return to SDFC.
For those patients who would like to do an infertility work-up before their new patient appointment, our physicians recommend the following (your PCP or OB may be able to order these for you):
- Fertility bloodwork
- Cycle day 3 AMH, FSH and Estradiol
- Vitamin D
- Hemoglobin A1c
- Antibody Screen
- CBC Screen
- Blood type
- Genetic Disease Mutation Screening
- HSG (Hysterosalpingogram) or SHG (Sonohysterogram)
- Semen analysis – you are able to schedule this at our office before your appointment
- Infectious disease testing for both partners
- RPR (Syphilis)
- Hepatitis B
- Hepatitis C
Current patients wishing for their records to be transferred from our center:
- Records Transfer Form: If you need to have your records released to a doctor outside of San Diego Fertility Center, please complete this form and return to SDFC.