HRC Fertility: New Appointment Request

Please complete the form in its entirety so we can best serve you and help you begin your journey towards parenthood. For aspiring parents interested in the promotional offers: please select which offer you'd like to explore with HRC Fertility during your initial consultation in the appropriate field below. We encourage you to read the disclaimer located at the bottom of this form.

Name

First Last

Address

Street Address Address Line 2 City State/Region/Province Postal / Zip Code

Country

Email *

Phone *

Text Messaging Opt-in

Yes, I consent to receiving texts for the purposes of receiving upcoming appointment confirmation messages and patient reminders from HRC Fertility. Text messaging rates may apply.

Date of Birth

Date of Birth *

MM/dd/yyyy

Interested in LGBTQ+ Program Info

Yes, please send me more information about your LGBTQ+ programs and resources.

****** Attention: Semen Analysis Patients ******

All Semen Analysis requests require a doctor's order. A valid ID, must be presented at your appointment.
Insurance patients MUST specify if test will be performed with Quest or LabCorp on your doctor's order.
Your physician, not HRC, will provide you with your results if the test is ordered with an outside lab.
A fee of $170 will apply at your time of visit for cash patients.

Primary Insurance

Name of Doctor Referral

Name of Friend or Family Referral

Name of Event

Name of Insurance Referral

Name of Print Ad

Name of Radio

Name of Agency Referral

Comments

APPT CODE

Submission Date

MM/dd/yyyy HH:MM AM/PM

Lead Source

Lead Source New

Lead Status

Influencer Name

DISCLAIMER:

Promotional packages are available for a limited time only. Cannot be combined with any other offers, discounts or promotions. Offers subject to change without notice. Additional restrictions may apply. Visit havingbabies.com/promotional-offers or contact us for full details. A non-refundable $75 appointment deposit is required to hold a new appointment. The deposit will be credited to the $350 new patient consultation fee that applies. The consultation fee will be credited towards your promotional package or IVF treatment only (does not include IUI or other procedures and/or surgeries. Flexible and convenient financing options are available through CapexMD & Future Family.

Terms and Conditions *

I accept the Terms & Conditions.

Verification Code *

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New Patient Consultation Request

DISCLAIMER:

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