New Patient Pre-Registration Form
You will hear back by the end of the next business day to schedule your appointment. If you do not hear back in this timeframe, please contact our Patient Experience Manager, Courtney Dickens, here: cdickens@atlanticreproductive.com. We will be calling you from (919) 248-8777. Please save this number to your contacts so you'll recognize our number and can answer when we reach out to schedule your appointment and provide access to our patient portal.
What fertility treatment are you seeking?
*
Infertility consultation (diagnosis & treatment)
Fertility Testing
Fertility Preservation (Egg & Sperm Freezing)
Recurrent Pregnancy Loss
IVF (In Vitro Fertilization)
IUI (Intrauterine insemination)
INVOcell
Genetic Testing
LGBTQ+ Family Building
Single Parent Family Building
Male Fertility
Semen Analysis
Other
Patient Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Best Phone Number To Reach You:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email Address:
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Best time to call you to schedule your appointment:
Morning
Afternoon
Do you have an OB/GYN?
Yes
No
Did your OB/GYN refer you?
Yes
No
Please provide the name of your provider and OB/GYN practice .
Do you have previous fertility treatment records?
Yes
No
Please fill out our Authorization to Release Medical Records by clicking here.
Do you have a partner?
*
Yes
No
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Your Partner Information:
Partner's Name:
*
Last Name
Partner Date of Birth:
*
-
Month
-
Day
Year
Date
Is your partner's address different than yours?
*
Yes
No
Partner's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Partner's Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Partner's Email Address:
example@example.com
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Next
Save
Are you working with the Filotimo Foundation?
Yes
No
Is this for a vasectomy consult?
*
Yes
No
Do you have insurance?
*
Yes
No
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Next
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Your Insurance Information:
Company:
*
Group Number:
*
Subscriber ID:
*
Subscriber Name:
*
Subscriber Date of Birth:
*
-
Month
-
Day
Year
Date
Does your partner have insurance different than yours?
Yes
No
Partner's Insurance Information:
Partner's Insurance Company:
Partner's Insurance Group Number:
Partner's Insurance Subscriber Name:
Partner's Insurance Subscriber ID:
Partner's Insurance Subscriber Date of Birth:
-
Month
-
Day
Year
Date
Back
Next
Save
How did you hear about Atlantic Reproductive Medicine?
Google or Internet Search
Facebook/Instagram
Friend or family member
Physician Referral
Digital Ad
Other
Please type any comments or questions you may have here:
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