Helping People
Become Parents®
Since 1988
Call: (800) 858-4832
Follow us:

IVF New England Patient Forms

Administrative Forms

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, 1 Forbes Road, Lexington, MA 02421. 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

Billing Forms

Recurring Credit Card Billing for Cryopreserved Specimens

 

Consent Forms

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.

5. Consent to Cryopreserve Embryos and Decisions for Future Disposition of Cryopreserved Embryos

6. Donor Sperm Acquisition Form

7. Receipt of Cryopreserved Embryos

8. Receipt of Cryopreserved Sperm

9. Genetic Screening Consent

10. Rubella Waiver

11. Consent for Treatment Without Varicella Immunity

 

IUI (Intrauterine Insemination)

IUI Consent

Ovulation and Intrauterine Insemination Treatment Guide Booklet

 

IVF (In Vitro Fertilization) Consent

Assisted Reproduction Consent for Treatment Guide Book (102014)

IVF New England assisted reproduction guide

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.

12.a. IVF Consent Form
12.b. Embryo Cryopreservation Storage Fee Information

13.  Frozen Embryo Transfer Consent

14.a. Oocyte (Egg) Cryopreservation Consent
14.b. Oocyte (Egg) Cryopreservation and Storage Fee Information

15.  PGD (Preimplantation Genetic Diagnosis) Consent

16.  Reciprocal IVF Consent

 

To Request Your IVF New England Medical Record

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.

17.  Medical Record Request Form from IVFNE

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 OB Medical Record Release Form below and fax it to our Medical Records Department at 781 674-1520.

18.  OB Medical Record Request