Forms

All of the forms below can be completed on your computer, and either e-mailed, snail mailed, or faxed to us at:

E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

Snail mail: Center for Reproductive Medicine and Surgery at 300 Park Street, Suite 460, Birmingham, MI 48009

Fax: 248-598-5925

Medical Records Request to Release Patient Information TO Dr. Mersol-Barg

For patients to give to any health care provider or hospital with records that may be needed for evaluation or treatment at the Center for Reproductive Medicine and Surgery.

Medical Records Request to Release Patient Information FROM Dr. Mersol-Barg

For patients to request records from the Center for Reproductive Medicine and Surgery to be sent to the patient or another health care provider.

Initial Medical History

For new patients to complete and return prior to the first appointment at the Center for Reproductive Medicine and Surgery. Dr. Mersol-Barg always reviews these forms prior to meeting with the patient.

Egg Donor Application

For healthy non-smoking women between the ages of 21-30 who are willing to donate their eggs in order to help other women have children.

Genetic Questionnaire for Egg Donors

For egg donors who have been accepted into our donor program. This form is required in order to conduct a genetic evaluation. After Dr. Mersol-Barg has analyzed it, then Shannon DeWall, MS, GSC, a certified genetic counselor, will study this form and conduct a phone consultation with the potential egg donor.

Genetic Consultation Intake Form

For patients that have concerns about possible genetic issues. After meeting with Dr. Mersol-Barg, he may request that you complete this form in order to investigate genetic-related issues. As soon as Dr. Mersol-Barg has analyzed it, then Shannon DeWall, MS, GSC, a certified genetic counselor, will also study the information. After these reviews, follow up appointments will be requested by Dr. Mersol-Barg and/or Ms. DeWall.

You will be contacted if we have any questions or if more information is needed prior to your appointment. If you have any questions or concerns, you are always welcome to phone us at 248-593-6990.