Patient Demographic Form

Patient Name

First Last

Sex of Patient

Female
Male

Date of Birth of Patient

Partner Name

First Last

Sex of Partner

Female
Male

Date of Birth - Partner

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Email

Patient Occupation

Patient Employed by:

Partner Occupation

Partner Employed by:

Purpose of Visit

examples; semen analysis, initial consultation

Patient's Social Security Number

Partner's Social Security Number

Do you have medical insurance?

Yes
No

Your Preferred Pharmacy

Your Pharmacy's Phone

Your Pharmacy's Zip Code

ZIP / Postal Code

May we leave messages, such as lab results appointments or other medical information on an answering machine or with another person who answers the phone at that number or in case of an emergency?

Yes
No

How did you hear about us?

Referring Physician Name

Referring Physician Phone

Referring Physician Fax Number

Referring Physician Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact

First Last

Emergency Contact Phone

PLEASE ENTER YOUR INITIALS TO SIGN THE QUESTIONNAIRE*

The undersigned declares that the above information is true and accurate:

Consent*

I confirm that all the information I have entered is correct and I have read, understand that LAIVF CLINIC will contact me using the information provided.

Privacy*

By using this form you agree with the storage and handling of your data by this website. *

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Patient Demographic Form

Patient Demographic Form

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