Patient Forms

Dear Patient:

Thank you for your diligence in completing the lengthy forms listed below. It will assist us in providing you with the highest quality treatment of infertility. Please return these forms addressed to the following as soon as possible:

The Women's Clinic, Ltd.
301 South 7th Avenue
Suite 245
West Reading, PA 19611

If there is any portion of this history which you would prefer to leave blank and review at your office visit, that would be fine. The "Male History" may be mail separately, if desired. It is critical that you obtain pertinent past medical records and have them sent to the Women's Clinic, Ltd. well in advance of your appointment. Dependent upon your provider, there may be a charge for these records, but they will allow us to avoid duplicative services and prompt treatment.

All information will be reviewed prior to your visit. Historic information regarding you is critical, in order that we may be of the greatest service to you immediately. This information also permits us to be the most cost effective for you by not repeating good and valid testing previously performed.

We assure you that this information will remain confidential.

Sincerely,

The Women's Clinic, Ltd.

Patient Intake History Form

Female History Form

Male History Form

Financial Policy

HIPAA Authorization Form

Privacy Policy

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