Language
English (US)
Arabic
Chinese
Spanish (Latin America)
Semen Analysis Appointment Request
Please fill out the entire form and submit for an appointment request. PLEASE NOTE: (CRBI does NOT provide a translator or use translation services. Please schedule an appointment when you are able to bring a translator, or your appointment will be cancelled.)
Patient Name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Can this phone number receive texts?
*
YES
NO
Patient Email
*
example@example.com
Partner's Name (patient name if single)
*
First Name
Last Name
Partner date of birth (patient DOB if single)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
Are you a new or returning patient to CRBI?
*
NEW Patient
RETURNING Patient
Reason for appointment
*
Semen Analysis Complete (Full Diagnostic, Sperm Count, Motility, Morphology, ETC.) $140.00
For ALL other appointments, including cryopreservation, please text: your FULL name, date of birth, type of appointment and if the appointment is time sensitive to 317-817-1147. A CRBI representative will contact you within 1 business day. (If you do not receive a call, please call 317-817-1147 option 4 or email info@reproductiveindiana.com).
If you have a referring doctor, please type their name below, if not please type N/A.
*
Referring doctor name or N/A
If you have an order from your physician, please upload your order here.
Browse Files
Drag and drop files here
Choose a file
If unable to upload an order, please text 317-817-1147.
Cancel
of
Appointment
*
Notes
Please provide any notes including requests for an earlier appointments if they become available.
Back
Next
Note: CRBI is Out-of-Network with ALL Insurance companies.
ALL payments are required at least 1 day PRIOR to your appointment. Have you submitted your $140.00 Semen Analysis payment?
*
YES
NO
Have you filled out and submitted a Patient Registration Form
*
YES
NO
Please provide a photocopy of your VALID identification (Please also remember to bring your VALID ID with you to your appointment. This is required.)
Appointment Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment Time
Hour Minutes
AM
PM
AM/PM Option
Reminder Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please verify that you are human
*
Submit
Should be Empty: