I authorize the release of my medical information relating to the fertility care and treatment received at the Center for Reproductive Medicine and Advanced Reproductive Technologies (collectively, CRM) to *, my Spouse/Partner. The information that I authorize to be released includes, but is not limited to, laboratory and diagnostic evaluation results that are pertinent to fertility treatment received at CRM.
I understand that I may revoke this consent for the use and release of information by written notice but my written revocation will not apply to information already released. This authorization will extend for no longer than one year from the date indicated below.
Please use your mouse, stylus, or finger to sign your name in this box.
7:00 am - 4:00 pm
7:00 am - 3:30 pm
7:00 am - 11:00 am(for monitoring and procedures only)
Copyright © 2018 Center for Reproductive MedicineIVF offices in Minneapolis and St. Paul, Minnesota
One fine body…