Patient Forms

PATIENT FORMS

Prior to your initial appointment with RMANJ, all patients must provide medical records specific to their care, as well as other written information. This allows our team to review the information before your visit so we can make your time with us the most productive and effective as we can. Please complete the New Patient Forms below.

Please complete and deliver the following forms at least 1-2 weeks prior to your appointment. New Patients MUST provide a government issued Photo ID at their initial appointment or they will NOT be seen.

COMPLETE YOUR NEW PATIENT FORMS

Each patient who visits RMANJ is directed to complete and submit a medical intake form. These medical histories allow our physicians to make the most accurate assessments of your fertility status and devise the most appropriate treatment plans. Please select the intake form that most accurately reflects you as a patient. If you are seeking our services as a couple, each partner in the couple must complete his or her own intake form.

Please complete the appropriate forms and return them to our office 1-2 weeks before your new patient appointment.

FEMALE INTAKE FORM

This is the Female Intake Form, depending on your health history. It should take you between five to ten minutes to complete. Click here to complete the form.

MALE INTAKE FORM

This is the Male Intake Form, depending on your health history. It should take you between five to ten minutes to complete. Click here to complete the form.

DEMOGRAPHIC FORM

This form collects your basic demographic information. It should take five to ten minutes to complete. Click here to complete the form.

SUMMARY HISTORY FORM

This form collects your infertility history. It should take five to ten minutes to complete. Click here to complete the form.

FPC INTAKE FORM

This is the FPC Intake Form. It should take five to ten minutes to complete. Click here to complete the form.

TRANSGENDER INTAKE FORM

This is the Transgender Intake Form. It should take five to ten minutes to complete. Click here to complete the form.

MEDICAL RECORD AUTHORIZATION FORM

This is the Medical Records Authorization Form. It should take five to ten minutes to complete. Click here to complete the form.

ADDITIONAL CONSENT AND POLICY FORMS

These additional forms will be provided to you upon arrival at your new patient appointment. To assist in the efficiency during registration, you may elect to complete these forms below in advance.

Please complete all forms and return them to our office 1-2 weeks before your new patient appointment.

GETTING YOUR PREVIOUS MEDICAL RELEASE RECORDS

Please complete the provided medical record release and send to your OB/GYN, urologist, previous fertility center or other medical provider to request your medical records.

We request a copy of your previous medical records to be forwarded to our office 1-2 weeks before your new patient appointment.

CANCELLATION POLICY

As you know, waiting for an appointment to begin fertility treatment can be stressful, so we ask you to be considerate of other patients who are waiting for their appointment with RMANJ. To ensure every patient is satisfied, here at RMANJ, we have developed guidelines for canceling and rescheduling new patient appointments. Please review the following and call the patient liaison department at 973-656-2089 with any questions: If it becomes necessary for you to cancel your appointment, we require at least 48 hour notice, so that we can contact other patients who may be able to take your scheduled appointment. If you do not contact us, RMANJ can bill you for the missed visit.

CANCELLATION RESCHEDULE POLICY

If you have cancelled your appointment three times, RMANJ will ask you to complete a Credit Card Authorization Form for payment. This will ensure us of your commitment to your next rescheduled visit. You will be charged for the initial consultation fee and when you come in for your consultation, you will be reimbursed this fee minus your co-pay.