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IVF Preliminary Appointment Data
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IVF Preliminary Appointment Data
Are you interested in pursuing IVF services as a single person or with a partner?
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First Name
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Date of Birth
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Have you previously been a patient at UI Health Care?
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Are you a military veteran?
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Have you been seen at the VA Hospital?
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Do you have a DD214?
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Referring Provider Information
Referring Physician (if applicable)
First & Last Name
City, State
Primary Care Provider
First & Last Name
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Do you want your health information sent to these providers?
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No
We are interested in
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IVF
Donor Eggs
Donor Embryos
Donor Sperm
Gestational Carrier
Preimplantation genetic testing (PGT)
I/we have cryopreserved (frozen) embryos in storage and desire to ship to UI Health Care.
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Yes
No
Have you had a sterilization procedure or sterilization reversal procedure?
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Yes
No
We are interested in being added to the "cancellation" list and could be available for an appointment on short notice.
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Yes
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Partner's information
First Name
Last Name
Date of Birth
Preferred Language
Mailing Address
CIty
State
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Zip
Phone
E-mail Address
Previous Patient Information
Have you previously been a patient at UI Health Care?
Yes
No
If so, please write your maiden name
Military Experience
Are you a military veteran?
Yes
No
Have you been seen at the VA Hospital?
Yes
No
Do you have a DD214?
Yes
No
Health Information
Have you had a sterilization procedure or sterilization reversal procedure?
Yes
No
Referring Provider Information
Referring Physician (if applicable)
First & Last Name
City, State
Do you want your health information sent to these providers?
Yes
No
Leave this field blank
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