Forms

Welcome to Reproductive Medicine & Infertility. We are excited that you have chosen our team to assist you in pursuing your dreams of parenthood. We understand the delicate needs of infertility patients. Our entire staff is committed to providing you with the best possible care and personal attention you deserve.

We require that the following forms be completed and mailed to our office before your appointment can be scheduled. This will enable us to better serve you on the day of your visit.

*If you utilize Adobe Reader to open the following PDF forms, please be sure to use the most-current version, 10.0.1, to prevent your web browser from freezing. Click here to download this version.

• Patient Registration Form
• Health and Social History Questionnaire
• Financial Policy
• Carrier Screening for Genetic Diseases Consent
• Ongoing Authorization for Release of Medical Information
• Authorization to Release Medical Records  – You must complete and send this form to your referring physician(s)
• Copy of the front and back of your insurance card(s). We require these prior to your visit in order to verify your insurance and health benefits.

Please mail completed forms to:
8901 W. 74th Street, Suite 269
Shawnee Mission, KS 66204

If you are a male coming in for a reproductive analysis, please read the following information.
Semen Analysis Collection

Notice to Unwed Patients
Shawnee Mission Medical Center's Seventh-day Adventist policy dictates a man and a woman must be married to procreate. Our office can diagnose why you are not getting pregnant, but unfortunately, we cannot enhance a pregnancy until the patient is married. We will refer all single women to RESOLVE (a national infertility organization) for physician referral assistance. To contact RESOLVE, call 888-959-0333 or visit resolve.org.

Notice to Parents
Please note that if you plan to bring a child to your appointment, you will need to make arrangements for a friend or relative to accompany your child. We are asking that they remain in the waiting room during your visit. Per office policy, children are not allowed in clinic areas. Not only do we care about your children and have a moral and legal obligation for their safety, but this also allows our staff to give you their undivided attention, which will maximize your visit. Thank you for your cooperation.

Our goal is to establish a comfortable and secure partnership with our patients. As a partner, you are encouraged to ask questions and discuss your treatment options. Please feel free to contact us at any time with questions regarding information or any concerns you may have.

Thank you for choosing Reproductive Medicine & Infertility. We look forward to personally meeting you and assisting you in making your dreams a reality.