Patient Forms

New Patient Packet

To make the most of your visit, our physicians prefer to review your medical history prior to your first appointment. Sending your records in advance will move the process along and enable you to bypass duplicating tests. You have options to fill out electronically and print, or print and fill out by hand. Please mail or fax your new patient packet to our office as soon as possible. A fax cover sheet is included at the end of the packet.

These forms can be filled out electronically. Click here to download a free version of Adobe Reader.

– Download New Patient Packet forms (right click to download)
– Copy of your insurance card and pharmacy card

Fax: 314-286-2455
Mail: Please send all mail to our Central West End Location

Fertility and Reproductive Medicine Center
4444 Forest Park Ave., Suite 3100
St. Louis, MO 63110

Individual Forms (these are included in the New Patient Packet)

Medical Records Release Form
Email communication consent form (Please sign and mail back)


Instructions for setting up Zoom for Virtual Visits

Fertility care is ideally suited for virtual visits particularly in the post COVID healthcare environment. Visits will typically begin at their scheduled time. Instructions on how to do the below will be shared with you at time of appointment scheduling.

  • Review the Virtual VIsit Tips from the WASHU Faculty Practice Plan
  • Make sure you complete e-check in via Mychart
  • Sign consents to permit electronic visits
  • Reminders and instructions on how to set up the visit are available here AND will also be sent 7 days prior to your visit

MyChart Sign Up

In order to make communication (e.g treatment planning, test results, etc) between our office and you more efficient, we will ask that you sign up for MyChart. MyChart is an online patient portal that provides a secure way to manage your health care information and communicate with your physicians at Washington University School of Medicine.
Sign up or log in »


Laboratory Consent Forms

Please click on the link to download the form you need.

FOR EMBRYOS
Receive Frozen Embryos (from an outside clinic/lab)
Transfer Frozen Embryos (to another clinic/lab)

FOR SEMEN
Semen Information Sheet (for all semen analysis, IUIs, sperm banking, fertility preservation)
Sperm Banking Packet (for new patients including fertility preservation)
Release Frozen Semen (for use or transfer)
Discard Frozen Semen
Anonymous Donor Frozen Semen (discontinue storage – donate or discard)


Genetic Screening Forms

Please click on the link to download the form you need.

WAIVERS
Decline genetic carrier screening or other genetic testing
Decline PGT-M or PGT-SR testing of embryos
Decline Partner/Donor testing after positive genetic test results

        SCREENING
        Genetic screening form


IVF and FET Consent Forms

For patients preparing to undergo IVF and or Frozen embryo transfer in our program.
Please click on the link to download the relevant form and fill out as instructed by your IVF Nurse Coordinator.

IVF Consent
FET Consent