ReproMed: New Patient Forms

Request a Consultation & Forms

To set-up a consultation, please fill out the form at the bottom of this page.

It would be our pleasure to set-up an appointment and review your case. The first step is to secure a referral from your family doctor. For your convenience, we have created a specialized referral form that you can print and take to your doctor to fill out. Another option is to have have your doctor use their existing format. Either way, once we have received the referral we are able to set-up the consultation here at the clinic.

Patient Referral Form

Before the consultation takes place (on site or via the phone), a member of our Patient Services Team will advise you which forms need to be completed and returned. These forms will be used to put together a chart to assist the Fertility Specialist. The Patient Services Team will advise you in advance of your appointment so you can schedule accordingly.

For all onsite appointments we require you to bring your Health Card and suggest that you bring your partner (if applicable).

Patient Forms for Initial Consultation

	Patient History Form
	Consent to Disclose Personal Health Information

Patient Forms Required for Subsequent Visit

	Consent for Testing
	Email Consent Form

Please fill out all the fields so we can serve you best. A member of our Patient Services Team will contact you to set-up an consultation.

First Name: *				Address:
Last Name: *				City:
Email: *				Province/State
Home Phone: *				Postal Code/Zip
Business Phone:				Ontario Health Card #
Cell Phone:				Referring Physician


Preferred Number to Reach You: home phone Business Cell
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