Download Forms

For your convenience, new patient medical forms, insurance information and questionnaires are provided below. Completing this information prior to your appointment will facilitate the process of data gathering by the physician. It will also allow you and your partner to have your questions answered adequately and in person.

The down-loadable forms are .pdf files and will require Adobe Acrobat 10 to view and complete. To download a free version of Adobe Acrobat 10, please CLICK HERE.

If you have questions regarding which forms are required for your specific needs, please feel free to contact our office.

Once downloaded, you may:
- Print the forms and fill them out by hand
(Fax them to our office 317-817-1810 or bring them in person).
- Fill them out on your computer using Adobe Acrobat, print them, sign and date the appropriate signature lines. (Fax them to our office 317-817-1810 or bring them in person).
NEW PATIENT FORMS
These forms are required when visiting Henry Fertility for the first time in order to create your patient chart.  Please bring all forms completed to your first appointment along with your insurance card, if applicable, and photo I.D.
NEW INSURANCE INFORMATION
Please print out and complete this form if there have been changes or updates to your insurance policy.  Send a copy of the front and back of the new card along with this completed form via email or bring it to your next appointment.  New information can be emailed to:  info@henryfertility.com
CHANGE IN PATIENT INFORMATION
Please print and complete a new patient registration form if you have a new address, or if your last name has changed.  Bring the completed form to your next appointment along with a photo i.d.
RELEASE OF RECORDS
Please complete this form and return it to our office in order to start the process of having medical records released.
OUTSIDE MONITORING REFERRAL FORMS
The following monitoring request form and physician order form are required to be completed and faxed to our office in order for any outside monitoring patient to be scheduled, patients must have a scheduled time. We do not accept walk ins. Once the order has been received with the required dates, the patient will be put on the schedule.
OUTSIDE MONITORING PATIENT FORMS
If you are scheduled to be monitored in our office, make sure your physician fills out the appropriate Monitoring Referral forms and faxes them to 317.817.1810.  Once we receive the appropriate forms from your physician, we will put you on the schedule.  When you come in for your first appointment, please bring in the completed Outside Monitoring Patient Forms so that we can make you a chart.
PHYSICIAN REFERRAL FORM
This form is for Physicians and/or medical professionals to refer a patient to Henry Fertility for treatment.  Please fax this form along with any pertinent medical records.