FERTILITY ENROLLMENT FORM by o2BEcILJ

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									                                                                                        FERTILITY
                                                                                     ENROLLMENT FORM
                                                                                                       (Please Print)
                                                                                                PATIENT INFORMATION
Patient’s last name:                     First:                                         Middle Init.                                 Mrs.                Marital status:        Single /        Mar
                                                                                                                                     Miss
                                                                                                                                     Ms.                     Div /         Sep /       Wid
Street address:                                                                                                                                           Birth date:

                                                                                                                                                                    /              /
City:                                                                                                        State:                     ZIP Code:                                      County:


Day phone no.:                                                   Night phone no.:                                                                   Allergies

(    )                                                           (    )
                                                                                          INSURANCE INFORMATION
Name of primary insurance:                                                   Primary cardholder’s name:                                     Group no.:                                                Member id:


Employer:                                                                    Patient’s relationship to cardholder:

                                                                                Child      Spouse      Self             Other
Name of secondary insurance:                                                 Secondary cardholder’s name:                                   Group no.:                                                Member id:


Employer:                                                                    Patient’s relationship to cardholder:

                                                                                   Child       Spouse   Self     Other:
                                                                                              PHYSICIAN INFORMATION
Prescriber’s last name:                  First:                                         Middle init.       Hospital/Clinic:                                             Office Contact Name:


Street address:                                                                                                DEA no.:                                                 UPIN:


City:                                                                                                          State:                           ZIP Code:                                   License no.:


County:                                                          Phone no.:                                                                         Fax phone no.:

                                                                 (    )                                                                    ( )
                                                                                           MEDICAL INFORMATION
Medical Criteria                                                                                      Prescriptions: (check all that apply)
Primary Diagnosis (ICD9 Code):                                                                            Gonal-f® (rFSH injection) ( quantity for 30 day supply)           Refill:
Secondary Diagnosis (ICD9 Code):                                                                      Dose            450 IU MDV         Quantity:                          RFF 450 IU Pen                         Quantity:
Current treatment              Intrauterine insemination/Controlled Ovarian Hyperstimulation                          RFF 75 IU PFS Quantity:                               RFF 900 IU Pen                         Quantity:
                               IVF                                                                                    RFF 300 IU Pen Quantity:                              Other:                                 Quantity:
                               Ovulation Induction (OI)
Prior Treatment:           #Prior IUI                   #Prior IVF              # Live Births         Directions:
History of PCOS       Yes          No                                                                     Cetrotide® (cetrorelix acetate for injection) (quantity for 30-day supply)
Failed clomiphene citrate for ≥ 3 cycles       Yes         No                                         Dose            0.25 mg kit        Quantity:                          Other:                                 Quantity:
                                                                                                                      3mg kit            Quantity:
Patient weight        kg/lb Height:                 BMI:               Date taken:       /    /
                                                                                                      Directions:
Lab values:                                                                                               Ovidrel® (choriogonadotropin alfa injection) (quantity for 30-day supply)
TSH level            FSH level                      Estradiol level          Prolactin level          Dose            0.25 mcg/0.5mL PFS Quantity:                          Other:                                 Quantity:
LH level             Progesterone level             Sodium                   Potassium
SCr                  AST                            ALT                                               Directions:
                                                                                                                  Crinone® (progesterone gel)                                              Refill:
Immunizations:
                                                                                                               Dose          8% Vaginal gel Quantity:                                      Other:                  Quantity:
    MMR Date:     /    /        Rubella Date:     /   /          Varicella Date:    /      /
                                                                                                               Directions:
Active or history of thromboembolic disorders:        Yes   No
If yes, provide details:                                                                                           Luveris® (lutropin alfa) (quantity for 30-day supply)
                                                                                                               Dose             75 unit SDV       Quantity:
                                                                                                                                Other:            Quantity:
Ship medication to:
                                                                                                               Directions:
    Patient Home                         Physician Office                    Other _____________




    Prescriber’s signature                                                                                                                        Date




                                     10905 Fort Washington Road ▪ Suite #403 ▪ Fort Washington, Maryland 20744 ▪
                                                       Phone: 301-203-3382 ▪ Fax: 301-203-3385

								
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