Incoming Medical Records Release - The Fertility Clinic

Please complete this form to request medical records to be released to The Fertility Center of Las Vegas/Ovation Fertility/Granite Surgery.

Patient Name*

First Last

Date of Birth*

Address

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

Phone Number*

Email Address*

I am scheduled at The Fertility Center of Las Vegas on:*

I hereby authorize:*

Insert your Doctor's name here.

FAX Number/Email address of the doctor’s office who has your medical records*

To release a copy of the following to The Fertility Center of Las Vegas: 8851 W. Sahara Ave # 100, Las Vegas, NV 89117 FAX: (702) 254 1213*

All relevant records within past 12 months
Chart Notes
Lab results
History and Physical
X-rays/Ultrasound reports
Operative reports
Embryo reports including FDA testing for egg and sperm provider, lab notes for embryo creation, type of media and thaw protocol

Records should be from within the past 12 months from an OBGYN, Primary Care, Perinatologist, or other Fertility Specialist. Relevant records include lab work, HSG, semen analysis, previous IUI/IVF treatment including cycle flow sheets and embryo information.

Medical records may include confidential information related to communicable disease, alcohol or drug abuse, genetic information, blood, breath, urine screens and mental health diagnosis and treatment.*

I understand
I do not understand

Do you authorize the release of this type of information?*

I do
I do not

This authorization will expire on:*

Patient or Personal Representative's Signature*

Please use a mouse on your desktop/laptop or a stylus / your finger to sign on a tablet.

Date*

Name of Person signing if not the Patient

First Last

Description of Rep. Authority to Act for Patient

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