Patient Forms, Orientation & Videos
All patients of NYU Langone’s Fertility Center are required to fill out the following forms, and we also encourage you to review our orientation materials and videos.
Streamline your check-in process for your first visit by printing and filling out the necessary forms below. If you have questions, please call us at 212-263-8990.
Initial Visit Forms
- Complete Patient Package (all of the forms below in one printout)
- Patient Demographic Form
- Review of Systems Form
- Notice of Privacy Practices Acknowledgement Form
- Preconception Genetic Questionnaire
- Pharmacy Data Sheet
- Zika Acknowledgement
- Financial Acknowledgement Form
- Authorization for Request of Medical Information to NYU Langone’s Fertility Center: for releasing medical information to NYU Langone’s Fertility Center
- Authorization for the Use and Disclosure of PHI: for requesting NYU Langone’s Fertility Center to release medical information
- Authorization for the Use and Disclosure of PHI—Instructions
- Authorization for Release of Surgical Films: for requesting original radiology films from NYU Langone’s Fertility Center
For patients of Madison Women’s Health and Fertility at NYU Langone’s Fertility Center:
Patient Orientation Sessions
Any patient undergoing in vitro fertilization (IVF) or egg freezing at the Fertility Center must attend an on-site orientation session conducted by our nursing staff before beginning the first cycle. Partners are encouraged to attend this session as well.
Even if you used another program, the orientation session provides patients with a great deal of information on our unique policies, operational and logistic information, consent reviews, research information, and staff contact information. Most importantly, the orientation session provides a thorough review of how the medical process works, including an overview of the medications involved in the process. The orientation introduces you to our embryology lab and our medical, nursing, and andrology staff. It also provides an overview of what activities are performed in each area.
Financial information is presented by our billing staff. They review each patient’s financial responsibilities relative to the specific benefit for medications and the cycle process.
To provide you with additional review of this information, the orientation presentation is now available online. Please note that this availability does not eliminate the need to attend an on-site session.
Please select the appropriate presentation to review:
- IVF Cycle for In Vitro Fertilization (egg retrieval with embryo transfer)
- Egg Freeze Cycle for Elective or Medical Egg Cryopreservation (egg retrieval only with delayed embryo transfer)
- Egg Thaw Cycle (egg thaw with embryo transfer)
Fertility Injection Training Videos
Fertility drugs, taken through injections, are used to stimulate a woman's ovaries to produce multiple mature eggs. This improves chances for fertilization and ultimately pregnancy. The most common medications used are called gonadotropins.
We have partnered with Freedom Fertility Pharmacy to offer a selection of online training videos that demonstrate how to self-administer various types of fertility drugs. You can view videos in English and Spanish.