Name Change Form
Please mail completed name change form with a copy of your current photo ID showing your new name to IVF New England - Attention: Patient Services, 450 Bedford Street, Ste 1000, Lexington, MA 02420. ACCEPTABLE PHOTO IDS: Any non-expired photo ID such as a driver's license, military ID or passport.
Laboratory Services for Non-IVF New England Patients Please complete and fax form to 781-674-1510 attn: Patient Services
1. Consent to Discard Sperm or Testicular Tissue
2. Consent to Discard Cryopreserved Embryos
3. Consent to Release Cryopreserved Sperm [to patient's custody, patient's representative/agent/designated facility]; This consent requires that the patient contact the Cryobiology Program to make arrangements.
4. Consent to Release Cryopreserved Embryos [to patient's custody, patient's representative/agent/designated facility or research]; This consent requires that the patient contact the Cryobiology Program to make arrangements.
New patients who may need to consider in vitro fertilization (IVF) should read this booklet, which provides information about IVF and related procedures. It is essential to review this information in preparation for your consent for treatment.
To request a copy (or copies*) of your medical record please complete the attached form and include the required information. Medical records are mailed to a patient within ten (10) business days from the date of receipt of this completed request form. The first copy of a patient’s medical record is released free of charge. * A fee of 25 cents per page, payable in advance, is charged for additional copies. It is recommended that patients have their medical record sent to their address and make any additional copies as needed for your physicians. Note: IVF New England cannot release records sent to IVF New England from another doctor’s office.
If you are being discharged from IVF New England to your obstetrician (OB) for pre-natal care we will automatically send a copy of your obstetrical ultrasound report, a letter outlining your treatment at IVF New England and your Patient Checklist to your OB. Some OBs may also want copies of your infectious disease and genetic test results. To request copies of these additional records please fill out the Medical Record Release Form and fax it to our Medical Records Department at 781 674-1520.