Please completely fill out this form, then click Print at the bottom of the page

*Required Field
*First Name:   *Address:  
Middle Initial: *City:  
*Last Name:   *State/Province:  
*Date Of Birth:   *Zip or Postal Code:  
*Social Security (Last 4 Digits):   *Home Phone:  
Marital Status: *Email:  

Patient Employer Information

Cell Phone:
Place Of Employment: Referred by:
Work Address: Occupation:
Work City: Work State/Zip Code:
Work Phone:
Type Of Employment:

Patient Partner Information

Driver's license?: First Name:
Driver's License Number: Middle Initial:
State Of Issue: Last Name:
Passport Number: Date Of Birth:

Insurance Information of Insured

Social Security:
Name: Home Phone:
Middle Initial: Cell Phone:
Last Name: Relationship:
Insurance Name: Additional Information:
Insurance Address: Occupation Of Insured:
Insurance City: Employer Name:
Insurance State/Zip: Employer Address:
Insurance Country: Employer City:
Insurance ID#: Employer State/Zip:
Insurance Group: Work Phone:
Insurance Phone: Email:

Primary Care Physician Information

Primary First Name: Primary Care Address:
Primary Last Name: Primary City:
Primary Phone: Primary State/Zip:
Primary Fax: Primary Country:

Emergency Contact Information

Contact First Name: Contact Address:
Contact Middle Initial: Contact City:
Contact Last Name: Contact State/Zip:
Contact Phone: Relationship:
Contact Cell: Contact Email:

Medical History

Are you or have you ever been exposed to any of the following during employment or military service:

Heat Toxic Fumes: Chemicals: Radiation:
Other: If other, please specify:
Blood Type:
Have you lost more than 20 pounds in the last year?
Do you follow a particular food diet or have any special dietary habits?
If yes, specify:
List the forms and frequency of regular vigorous exercise (swimming,cycling,running) and age you began:
Exercise/Hrs Week/Age:
Do you frequently take saunas or steam bath?
Have you ever had surgery in the pelvic area?
If yes, specify date and type of surgery:
Have you ever received X-rays in the pelvic area for therapy or diagnosis?
If yes, specify:
Have you ever been treated for cancer?
If yes, specify:
Within the last year, have you taken any prescription medication?
If yes, specify:
Anemia Diabetes Herpes Pneumonia
Blood Transfusion Breast Tenderness Breast Discharge Testes Injury
Testes Infection Testes Tumor Epilepsy Gallbladder Problems
Liver Problems Hepatitis Ulcers Colitis
Kidney Infection Visual Disturbances Mumps Measles
German Measles Scarlet Fever Seizures Arthritis
High Blood Pressure Chlamydia Gonorrhea Syphilis
Thyroid Problems Prostatitis Parasitic Infection Dizziness
Tuberculosis Bronchitis Cystic Fibrosis Rheumatic Fever
Nongonococcal Urethritis Neurological Problems
Are you taking any over-the-counter medication?
If yes, specify:
Have you had a high fever ( over 102 F ) during the past 3-4 months?
If yes, specify:
Do you drink alcohol?
If yes, specify (Wine/Beer/Cocktails) and how many glasses per week:
Do you or have you smoked cigarettes?
If yes, specify how many cigarretes per day:
Illicit or recreational drugs (Marijuana, Cocaine, etc). If you would feel more comfortable not writing anything down, please discuss this directly with your physician.
Do you have any Allergies?
If yes, specify:

Sexual History

Are you circumcised?
When you were a child, were both testes descended into the scrotum?
At what age did you begin shaving regularly or start to grow beard?
Have you been married before?
If yes, how many times?
Have you ever produced a child with another partner?
If yes, how long did it take to produce the child?
Date when child was produced?
Do you have trouble getting an erection?
Do you have trouble maintaining an erection?
Do you have trouble with ejaculations?
If yes, premature ejaculation?
If yes, retrograde ejaculation?
Do you feel that some of your ejaculate is deposited in the vagina?
Do you ever have orgasms without ejaculation during masturbation?
Do you have any discharge from the penis?
How many times per week do you and your partner now have intercourse?
How many times do you have intercourse around ovulation?
Have you ever noticed a change in your sexual drive recently?
Is there a family history of infertility?
If yes, who(list all the members and relationship to you):
Is there a history of hormonal disorders in your family?
If yes, list who (relationship to you) and what type:

History of Fertility Therapy

Have you been treated for infertility before?
If yes, who was your physician:
What cause of infertility was diagnosed?

What drugs have you taken for infertility? Check all that apply:

HCG HMG Urofollitropin or FSH Bromocriptine
GnRH or LHRH Clomiphene Citrate Tamoxifen Testosterone or Male Hormone
If yes to any of the above, please specify:
Have you ever had varicocele or repair?
If yes, when?
Have you ever had vasectomy reversal or repair?
If yes, specify:
Have you or your partner ever received treatment with artificial insemination?
If yes: Your Sperm Donor Sperm
Have you and your partner ever received treatment with In Vitro Fertilization?
If yes, please explain:

Which of the following tests have you had performed? Check all that apply:

Semen Analysis When? and Results:
Chlamydia Test When? and Results:
Mycoplasma Test When? and Results:
Antibody Test When? and Results:
Chromosome Test When? and Results:
Testicular Biopsy When? and Results:
X-Ray or Ultrasound Test When? and Results:
Hormonal Tests When? and Results:
Thyroid Test When? and Results:
Other (Hormonal Tests: FSH, LH, Prolactin, Testosterone) When? and Results:
If your partner is seeing a doctor for evaluation of infertility, specify physician name and location:
Does your doctor feel that your partner has an infertility problem?
If yes, what is the diagnosis and how is she being treated?
Has she ever produced a child with another partner?


Fee Policies for Patients

Boca Fertility will bill your insurance for coverage charges incurred in our office. Your deductible and co-payment are due at the time of your visit.

Some services provided by our office may be non-covered. If we have been informed that the services is not covered, you will be responsible for payment in full at the time of the visit. Otherwise, we will file a claim and bill you if its denied. You will be held responsible for any charges not paid by the insurance company, regardless of the reason. Payment is due in full by the 30th of the month in which statement is sent. We accept cash, check, MasterCard, Visa, or Discover. We also offer our patients the option of applying for credit with a medical finance company. If you will be paying cash, please note that we do not keep change in our office. (If you do not have the exact amount, we can credit your account for the overpayment or mail you a check.)

A $30 charge is applied to any check returned by the bank. Past due accounts are assessed a 1% monthly late charge. Accounts sent to an outside collection agency are responsible for all legal fees and collection costs. If your insurance coverage is terminated or if you switch policies, it's your responsibility to let us know this prior to undergoing further services. It is possible that at some point your insurance company may request a copy of your file in order to determine whether your treatment is for a non-covered or pre-existing condition. This is a matter over which we have no control; we cannot withhold or alter records. There is a nominal handling fee for making those copies. The medical personnel in our office, including Dr. Peress, are devoted exclusively to your medical care. Please direct all matters relating to fees, billing, and insurance only to the business office. I understand and agree to all of the above. I hereby authorize the release of medical information to my insurance company and authorize payment of medical benefits to Dr. Peress and/or Boca Fertility.

Payment is due at the time of service. If you wish to know the fee for any service in advance of scheduling, please feel free to ask the receptionist. By typing your initial in the box below you agree to accept the terms of our fees policies.


*Your Initials: