Consistently above the national birth rate average in all measured categories*

Patient Registration (Male)

  • Please enter a number greater than or equal to 0.
  • Please list each medication you are allergic to and the symptoms of your reactions.
  • Please enter a number greater than or equal to 0.
    Coffee, soda, tea, energy drinks, etc.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
    A drink is 12 oz of beer, 5 oz of wine, or 1.5 oz of hard liquor.
  • Not including routine x-rays.
    Diethylstilbestrol (DES), also known as stilbestrol or stilboestrol, is an estrogen medication which is mostly no longer used.
  • This form was developed by the American Society for Reproductive Medicine to assist physicians and patients in obtaining a complete infertility history.