Forms
Pre-appointment Medical History Intake Forms
You can fill out this form before your appointment. Completing the forms before your appointment will save you and your doctor time in the office. Print it, fill in your information, and bring it with you.
The form asks for information about your medical history and prior fertility treatments, so you’ll want to have that information on hand.
There are four forms: two for female medical history and the other two for male medical history. Please print and fill out both forms if applicable.
Female Medical History Intake form (183kB) – you can print blank form, fill it out and bring it with you to your appointment.
Female Fertility Questionnaire - same female form as above, but you can fill it out online, save it and email it to the Duke Fertility Center ahead of your appointment.
Male Medical History Intake form (26kB) – you can print blank form, fill it out and bring it with you to your appointment.
Male Fertility Questionnaire – same male form as above, but you can fill it out online, save it and email it to the Duke Fertility Center ahead of your appointment.
Early Pregancy Study - This consent allows Duke Fertility Center physicians to confidentially use your blood and urine samples to study pregnancy hormone (hCG) levels during early pregnancy.
Hyperglycosylated hCG Study (PDF 102 KB)
Consent Forms
When you come to our office you’ll be asked to sign consent forms for procedures. Here are some of examples of in vitro fertilization (IVF) forms. Read them to find out what to expect when you come for your visit.
Assisted Reproductive Technologies Consent (PDF, 15KB)
This consent form is for both partners to give voluntary consent to participate in IVF.
Conscious Sedation Consent (PDF, 88KB)
This consent form gives us permission to give the patient Fentayl and Versed through an IV to help her relax during the oocyte retrieval.
Cryopreservation of Embryos (PDF, 11KB)
This consent form to us permission to freeze or cryopreserve any remaining viable embryos not transferred to the uterus during an IVF cycle.
HIV Consent (PDF, 74KB)
HIV testing is part of the IVF screening process. Both partners must be tested.
Request and Authorization Form for Transvaginal Occyte Retrieval (PDF, 157KB)
This consent form gives us permission to perform the oocyte retrieval. It lists the risks associated with the procedure.
Request and Authorization for Micromanipulation of Oocytes In Vitro for Assisted Fertilization (PDF, 18KB)
Also called the intracytoplasmic sperm injection (ICSI) consent. This consent form is for individuals with male factor infertility. This procedure would be recommended to the patient based on partner’s semen profile.
