Delivery Information

Delivery Information Form

IVF clinics are required to report IVF cycle data and outcomes to the Center for Disease Control (CDC) through the Society for Assisted Reproductive Technology (SART). Both SART and CDC publish annual statistical summary reports on reproductive medicine. These reports are statistical summaries only, and do not include patient names or other identifying information. We appreciate you completing the following information regarding the outcome of your treatment.

Birth Mother's Full Name*

First Last

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email Address*

Original Due Date*

MM

DD

YYYY

Delivery Date*

MM

DD

YYYY

Cycle Type:*

IUI
IVF
Timed Intercourse

Did the pregnancy result in a live birth?*

Yes
No

Type of delivery:*

Vaginal
C-Section

Did you have any complications with your delivery?*

Yes
No

If yes, please explain*

Baby's Information

Baby's Information*

Use the "+" button to add extra lines.

Sex	Weight	Length

Birth Defects?*

Yes
No

If yes, please explain*

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