Schedule a Consultation

** This request form is for a new patient requesting an initital consultation with one of doctors. If you are an exisiting patient in need of a follow-up consultation please click here.

Welcome to New Hope Fertility Center. Please take moment to answer the following New Patient Information questionnaire:

Our New Patient Coordinator will receive your information and contact you the following business day to schedule an appointment with our doctor.

If you prefer, you can call us directly at (212) 400-9614 to set up a consultation. Please be advised that a similar questionnaire will need to be completed if not done through our website.

If you are currently our patient please click here.

If you are not a patient please click next button below to get started.

Basic Information

Male Female

First Name:		Last Name:
Address:		Apt #:
City:		State
			Zip:
Home Phone:		Work Phone:	Ext:
** Please use digits only for phone numbers, i.e. (212) 517-7676 would be 2125177676.
Cell Phone:		Preferred Phone:
Email Address:		Confirm Email:
Date of Birth:	/ /	SSN:
	mm / dd / yyyy

Notes:

I am currently:

In a relationship with a male partner

In a relationship with a female partner

Single

Partner Information

Male Female

First Name:		Last Name:
Address:		Apt #:
City:		State
			Zip:
Home Phone:		Work Phone:	Ext:
** Please use digits only for phone numbers, i.e. (212) 517-7676 would be 2125177676.
Cell Phone:		Preferred Phone:
Email Address:		Confirm Email:
Date of Birth:	/ /	SSN:
	mm / dd / yyyy

Insurance

Do you have insurance? Yes No

Primary Insurance		If other:
	Group#:	Member ID#:
	Provider or customer service telephone:
Secondary Insurance		If other:
	Group#:	Member ID#:
	Provider or customer service telephone:

If you do not know or would like to know your coverage, please call the members services number on the back of your insurance card and ask about infertility benefits. If your insurance is not listed above, it is not accepted by New Hope Fertility. Please note that we do not participate with Medicaid plans.

New Hope Fertility Center in New York provides the best IVF, with specialties in Natural Cycle and Mini-IVF™ while running the largest Egg Banking and International Egg Donor Program.

Schedule a Consultation

Basic Information

Partner Information

How did you FIRST hear about New Hope Fertility Center?

Online (Click to see options)

Referral (Click to see options)

Print Source (Click to see options)

Please select the reason for your visit.

Insurance

How would you like to be contacted regarding your initial office visit?

How would you like to be contacted regarding subsequent treatment protocols?

What day/times would be optimal for your initial office visit?

If you are travelling to NY to see us, what dates will you be here?

If you cannot sufficiently communicate in English, in which language would you require assistance?

Weekdays


Weekends

New Hope Fertility Center in New York provides the best IVF, with specialties in Natural Cycle and Mini-IVF™ while running the largest Egg Banking and International Egg Donor Program.

Schedule a Consultation

HIPPA Consent Form

Basic Information

Partner Information

How did you FIRST hear about New Hope Fertility Center?

Online (Click to see options)

Referral (Click to see options)

Print Source (Click to see options)

Please select the reason for your visit.

Insurance

How would you like to be contacted regarding your initial office visit?

How would you like to be contacted regarding subsequent treatment protocols?

What day/times would be optimal for your initial office visit?

If you are travelling to NY to see us, what dates will you be here?

If you cannot sufficiently communicate in English, in which language would you require assistance?