Patient Forms

For your convenience, our most important patient forms are on our website. Save time by completing patient forms before your visit. If you have any questions or concerns, please call our office (602) 351-5327 and speak with our helpful staff. In order to view these forms, you will need Acrobat Reader. Click here to go to Adobe’s website to download a free version of Acrobat Reader to your computer.

Available Forms

Download and complete the appropriate patient forms, and then upload the completed files to the Patient Forms Submission area below.

New Patient Package

Genetics Screening Form

HIPPA Electronic Email Release

Medical Records Release

In Vitro Fertilization (IVF)

Hysterosalpingogram (HSG) Referral Form

Male Patient Form

Semen Collection Form

Ordering Donor Semen Form

Specimen Storage Agreement

Ordering Tests

Transfer & Release Forms

Termination of Storage Forms

Formas de Español


Patient Forms Submission


New Patient Package

Please fill out the New Patient Packet – a fillable PDF form. Please type directly into the form and save it to your computer. You can then upload it to the form submission area above or print and fax it to us at (602) 343-2766. Please complete and send at least 5 days before your first visit.

New Patient Packet


Genetics Screening

Please print and fill out the Genetics Screening Form and fax to us at (602) 343-2766 or upload it to the form submission area above at least 5 days before your first visit.

Genetics Screening


HIPPA Electronic Email Release

Please read, sign and return to us with your preferred email, in order to provide ARMS permission to communicate with you via email. Please note that ARMS cannot email your protected health information to third parties, such as doctors’ offices.

HIPPA Electronic Release


Medical Records Release

Please download this form, complete it to request records from ARMS and/or to request records from your treating physicians. Please fax it to your previous physicians as those records would be helpful to us. Please send one form to each prior physician. Please note that ARMS cannot email your protected health information to third parties, such as doctors’ offices. We will fax or mail to third parties.

Medical Records Release


In Vitro Fertilization (IVF)

IVF Teaching Visit Outline
Pre-Op IVF Instructions
Genetic Considerations Related to Intracytoplasmic Sperm Injection (ICSI)


Hysterosalpingogram (HSG)

HSG Referral Form
HSG Instruction Sheet

Fact Sheets about Fertility and Drugs

Infertility Fact Sheet


Male Patient

This form is to be filled out for every sperm specimen being analyzed at ARMS. This form must be filled out for every semen specimen.   If collecting at home, please call to schedule  an appointment prior to dropping off a collected specimen.

Male Patient Form


Collection Form

This is the guidelines for the collection of semen specimens for semen analysis and sperm preparations for insemination at ARMS. Please read this form carefully prior to producing a semen specimen to ensure the best quality specimen is obtained. If collecting at home, please call to schedule  an appointment prior to dropping off a collected specimen.

Semen Collection Form


Ordering Donor Semen

If ordering donor semen for use at Arizona Reproductive Medicine Specialists, this form must be filled out and sent to our office.

Instructions and Order Form for Ordering Donor Semen


Storage

If you are planning to store any frozen specimens at ARMS, this Contract must be signed. Please note that any donor semen stored at ARMS must be from a bank certified by either The American Association of Tissue Banks or the New York State Board of Health. This is done to ensure the safety of all specimens stored at ARMS.

Specimen Storage Agreement


Ordering Tests

Instructions for physicians (outside of ARMS) that would like to order sperm preparations, consults or andrological tests from the ARMS laboratory for their patients. Also, included is a list of services from the ARMS laboratory and prices for those tests (pricing is subject to change without notice). If you want an accurate price for any service, it is always in your best interest to call the office.

Order Tests


Transfer & Release Forms

Transfer to ARMS: Prior to shipping any frozen embryos or sperm to ARMS, this form must be filled out.
Transfer from ARMS: Prior to shipping any frozen embryos or sperm from ARMS, this form must be filled out.
Release Instruction: Instructions for how to proceed in shipping embryos or sperm from one site to another. To be used with the “Transfer” forms.
FDA Release – Eligibility Determination Form: This form must be sent to ARMS by the originating laboratory whenever embryos or sperm are shipped to ARMS.


Termination of Storage Forms

For the proper disposal of embryos or sperm currently stored at ARMS, this form must be filled out and notarized.

Termination of Storage Form


Formas de Español

Paquete de Pacientes Nuevos