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Patient Information

Married/Single?*

Patient Relationship to the Responsible Party*

Employer Information

Donor Information

What is the best number at which to contact you?*

Is it okay to leave you a message at this number?*

Donor Information and Medical History

Education*

Please list any extra-curricular activities you participated in during your high school years

Please list any special awards you received

What subjects did you enjoy most?

Please list any college/advanced degree awards you received

Hair type*

Complexion*

Sun Exposure*

Body Build*

Donor Information and Medical History (cont.)

Any unique facial features (dimples, cleft chin, large smile, moles, large eyes)

Adult Shape Of Lips*

Adult Shape Of Mouth*

Adult Shape Of eyes*

Adult Spacing of Eyes*

Adult Size Of eyes*

Adult Shape Of Face*

forehead set*

Adult Nose*

Adult Nose Profile*

Has anyone ever told you that you look like someone famous? If so, who?

sexual orientation*

Are you right or left handed?*

How would you describe your personality and character?

Have you ever been given a personality test and if so, what were the results?

How would you describe your childhood?

What is your favorite childhood memory?

Donor Information and Medical History (cont.)

What is your happiest moment and your hardest moment you have experienced to date in your life?

What do you like to do in your spare time?

What are your plans/goals for your future?

What are you most proud of?

Who is the most influential person in your life and why?

What hobbies do you enjoy?

Do you have any special musical/artistic/athletic/culinary or other talents?

Why do you want to be a donor?

Favorite quote?

Is there anything else you would like a potential recipient to know about you?

Donor Information and Medical History (cont.)

Fertility Information

Have You ever been pregnant before?*

If you have children, do they have any health problems?

If yes, please specify:

have you ever donated eggs before?*

If yes, when and where?

Personal Health

Vision (uncorrected)*

Do you wear glasses/contact lenses?*

Are You:*

Hearing: normal?*

If no, please specify:

have you ever had surgery?*

If yes, please specify:

have you been hospitalized for other reasons?*

If yes, please specify:

have you ever had any major illnesses?*

If yes, please specify:

are you currently taking any medications?*

If yes, please specify:

what medications have you been on in the past?

do you have any food allergies? if so, please list:

Donor Information and Medical History (cont.)

do you have any environmental allergies? if so, please list:

Do you currently use any drugs ex. marijuana, cocaine, narcotics? (this information is strictly confidential)

Do you drink alcohol?*

Do you smoke cigarettes?*

if yes, how often?

Are your family members generally:*

have any of your relatives had more than one miscarriage, any stillbirths or early childhood deaths?*

if yes, please explain that person's relationship to you, the cause(s) of their child(ren)'s death(s) and the child(ren)'s age(s) at death:

have any of your family members had one or more children with serious birth defects?*

if yes, please specify:

Donor Information and Medical History (cont.)

Fertility Information

paternal Grandfather

paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Father

Mother

Brother #1

Brother #2

Brother #3

Brother #4

Sister #1

Sister #2

Sister #3

Sister #4

Child #1

Child #2

Child #3

Child #4

paternal Aunts

paternal Uncles

Maternal Aunts

Maternal Uncles

Donor Information and Medical History (cont.)

Family History

Stroke

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  • You
  • Mother
  • Father
  • Sibling
  • Grandparents
  • Aunts/Uncles
  • Cousins

Heart Disease

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  • You
  • Mother
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  • Sibling
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Hardening of arteries

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  • Mother
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High Blood Pressure

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  • Mother
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Anemia

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Hemophilia/bleeding problem

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  • You
  • Mother
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  • Sibling
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Leukemia

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Immune deficiency disorder

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Thalassemia

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  • Mother
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Tay-Sachs

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Sickle Cell

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  • Mother
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Hay Fever

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Asthma

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Emphysema

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Tuberculosis

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Lung Cancer

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Other Lung Disease

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  • Mother
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Ulcer of Duodenum or Stomach

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  • Mother
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Gallstones

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Hepatitis

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Pyloric Stenosis

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Liver Disease

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Ulcerative Colitis

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Crohn's Disease

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Intestinal Cancer

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Other Cancer of Digestive System

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Other Digestive Disease

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  • Mother
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  • Sibling
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  • Cousins

Diabetes

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Thyroid Disease

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Other Endocrine Disease

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Donor Information and Medical History (cont.)

Family History (cont.)

Cleft Lip or Palate

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  • You
  • Mother
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  • Sibling
  • Grandparents
  • Aunts/Uncles
  • Cousins

Club Foot

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Congenital Heart Disease

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Other Birth Defects

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Kidney Disease

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Other Urinary Tract Disease

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Undescended Testicle

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Hypospadiasis

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Prostate Cancer

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Uterine Fibroids

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Cancer of Cervix, Ovaries, or Uterus

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Mental Retardation

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Down's Syndrome

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Senility Before Age 50

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Mental Disorder

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Crippling Disorders

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Schizophrenia

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Manic Depressive Disorder

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Multiple Sclerosis

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Epilepsy

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Hydrocephalus (Water on the brain)

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Spinal Cord Disorders

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Huntington's Chorea

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Other Nervous System Disorders

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Deafness Before Age 50

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Cataracts Before Age 50

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Blindness

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Glaucoma

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Muscular Dystrophy

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Other Chronic Muscle Diseases

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Spina Bifida / Other Spinal Deformity

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  • Mother
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Arthritis

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Hereditary Low Back Disease

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Eczema

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Skin Cancer

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Breast Cancer

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Other Cancer not Mentioned Above

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Alcohol Related Problem

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  • Mother
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ADD / ADHD

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Alcoholism

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Drug Addiction

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Other (please list below):

Women's History

General Information

Gynecologic History

Do you have any symptoms at time of ovulation (i.e., pain)?*

Amount of Flow*

Is Cramping*

Have you ever been treated for pelvic infection?*

did your mother take any medications while pregnant with you?*

History Of

Pelvic Pain*

Uterine fibroids*

PCOS*

Adenomyosis*

Endometriosis*

Uterine polyp*

Sexually transmitted disease*

Galactorrhea*

Pelvic inflammatory disease*

Acne*

Abnormal pap smear*

Ovarian Cysts*

Treatment of abnormal pap smear*

Women's History (cont.)

Sexual and Contraceptive History

Is Intercourse Painful?*

Do you use birth control pills*

Record of ALL Pregnancies

For each, please provide: Year, Full Term, Preterm, Miscarriage, Termination, Complication, Fertility Treatment

Pregnancy #1

Pregnancy #2

Pregnancy #3

Pregnancy #4

Pregnancy #5

occupational / leisure history

Exposure to chemical / x-rays in work or hobby*

Caffeine*

Smoking (tobacco)*

Alcohol*

Marijuana*

Nutritional supplements*

Narcotics (heroin, methadone)*

Amphetamines*

Hallucinogens*

Have you had any tattoos, ear or body piercings within the past year?*

Women's History (cont.)

Medical History

In the past six months have you been exposed to:

  • Toxic Chemicals
  • Sprays
  • Fumes/Exhaust
  • Radiation
  • Flea Powder/Spray
  • Lead or Lead Products
  • Asbestos/Asbestos Products
  • Other Toxic Products (Please Specify)

Have you had any of the following?

  • Blood Transfusion
  • Major Radiation or X-ray Exposure
  • Syphilis
  • Gonorrhoea
  • Non-specific Urethritis
  • Venereal Warts
  • Herpes
  • Chlamydia
  • Mumps
  • Measles
  • Chicken Pox
  • Rubella (German Measles)
  • Rheumatic Fever
  • Elevated Blood Pressure
  • Heart Murmur
  • Heart Disease
  • Diabetes
  • Lung Disease
  • Liver or Gall Bladder Disease
  • Jaundice
  • Kidney Infections
  • Hepatitis
  • Kidney Stones
  • Gout
  • Urinary Tract Abnormalities
  • Thyroid Disease
  • Arthritis
  • Auto-immune Diseases (Lupus, Rheumatic Arthritis etc.)

Do you have any allergies to medications?*

Please list any medications you are now taking or have taken in the past (except antibiotics). Please include supplements.

Current Use

Past use

Have you ever been treated for any mental illness?*

FDA Screening Questionnaire

Egg Donor or Genetic Parent?*

1. Female: In the past 12 months, have you had sex with a man, who has had sex with another man in the past 5 years? Male: Have you had sex with another male in the past 5 years, even once?*

2. Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular and subcutaneous injection?*

3. Have you received human-derived clotting factor concentrates for hemophilia or a related clotting disorder?*

4. In the past 5 years, have you been given money or drugs in exchange for having sex?*

5. In the past 12 months, have you had sex with anyone who would answer yes to any of questions 1, 2, 3 or 4?*

6. In the past 12 months, have you had sex with a person known or suspected to have HIV infection, active hepatitis B infection or hepatitis C infection, clinically active hepatitis B infection, or hepatitis C infection?*

7. In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B and/or hepatitis C infected blood through percutaneous inoculation (e.g., needle stick) or through contact with an open wound, non-intact skin or mucous membrane?*

8. In the past 12 months have you had an accidental needle stick, sharp instrument injury, contact with human blood, serum or plasma in the eye, mucus membranes (lips, interior of nose) or sores.*

9. In the past 12 months, have you been in jail for more than 72 consecutive hours?*

10. In the past 12 months, have you lived with (resided in the same dwelling) another person who has Hepatitis B or clinically active (symptomatic) Hepatitis C infection?*

11. In the past 12 months, have you had ear or body piercing or tattooing? (If no, go to question 12. If yes, go to question 11a)*

11a. Did you have a tattoo in the past 12 months? (If no, go to question 11c)*

11b. Were the instruments sterile?

11c. Did you have ear, skin or body piercing performed in the past 12 months? (If no, go to question 12)

11d. Were the instruments sterile?

FDA Screening Questionnaire (cont.)

12. After age 11 have you had a clinical diagnosis of symptomatic viral hepatitis? (If yes, go to question 12a)*

12a. Was the hepatitis identified as Hepatitis A (ex. reactive IgM anti-HAV test), Epstein-Barr, or cytomegalovirus?

13. Have you, your sexual partner(s) or any member of your household ever had a transplant or medical procedure that involved being exposed to live cells, tissues, or organs from an animal? (If no, go to question 14)*

13a. If the person referred to in question 13 was a member of your household, were you exposed to that individual’s blood, saliva, or other body fluids (e.g., through deep kissing, shared toothbrushes, razors, or needles, or through open wounds or sores)

14. Have you been diagnosed with West Nile Virus (including diagnosis based on symptoms and/or laboratory results, or confirmed WNV viremia) in the past 120 days? (If no, proceed to question 15)*

14a. Have you been suspected of having West Nile Virus in the past 120 days?

15. Within the past 8 weeks, have you had a smallpox vaccination or had close contact with the vaccination site of anyone else? (Examples of close contact include touching the site, the bandages covering the site or handling bedding or clothing that has been in contact with an unbandaged vaccination site.) (If no, go to question 16)*

15a. Did you have a smallpox vaccination? (If no, go to question 16)

15b. Did scab separate/fall off by itself?

16. If you had close contact with a smallpox vaccination recipient, have you had any new skin rash or sore since the time of contact? (If no, go to question 17)*

16b. Did you have any illness or complications from your vaccination or from your close contact with someone who was vaccinated?

17. In the past 12 months have you had or been treated for syphilis, chlamydia, or gonorrhea?*

18. Have you or any of your blood relatives been diagnosed with Creutzfeldt-Jakob disease (CJD)?*

19. Have you been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system or other neurological disease of unknown etiology?*

20. Have you ever received growth hormone made from human pituitary glands?*

21. Have you ever received a non-synthetic dura mater (brain covering) graft?*

22. From 1980 through 1996 were you a member of the U.S. military, a civilian military employee or a dependent of a military member or civilian military employee? (If no, go to question 23)*

22a. Did you spend a total of 6 months or more associated with a military base in any of the following countries, Germany, Belgium, or The Netherlands between 1980 and 1990; or Greece, Turkey, Spain, Portugal, or Italy between 1980 and 1996? (Please provide details)

FDA Screening Questionnaire (cont.)

23. Since 1980, have you ever lived in or traveled to Europe? (Includes Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, and Yugoslavia). (If yes, go to question 23a and please list dates and places traveled. If no, go to question 24. Please provide details)*

23a. From the beginning of 1980 through the end of 1996 did you spend time that adds up to 3 months or more in the U.K.? (Includes England, Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar and the Falkland Islands).

23b. Since 1980 have you received a transfusion of blood or blood components in the U.K. or France?

23c. Since 1980 have you spent time that adds up to 5 years or more in Europe (including time spent in the U.K. between 1980 and 1996)?

24. Have you ever been to or had sexual contact with anyone who was born in or lived in certain countries in Africa (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria) after 1977?*

25. Have you received a blood transfusion or any medical treatment that involved blood in the countries listed in Question 24?*

26. Have you been diagnosed with Zika virus infection, visited in an area with active Zika virus transmission, or had sex with a male with either of those risk factors, within the past six months?

Eligibility Determination*

HIPAA Notice of Privacy Practices

Please review this notice carefully. It describes how medical information about you may be used and disclosed and how you can get access to this information.

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. As another example, your protected health care information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for hospital admission.

Healthcare operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

Use required by law: We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law; Public Health issues as required by law; Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Funeral Directors; and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; Inmates; Required Uses and Disclosures. Under the law, we must make disclosures to you and when, required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance to the use or disclosure indicated in the authorization.

Your Rights

The following is a statement of you rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this.

Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

You have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, or your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our HIPAA Compliance Officer of your complaint. We will not retaliate against your for filing a complaint.

This notice was published and becomes effective on April 14, 2003

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main number.

Signature Below is only an acknowledgement that you have received this Notice of our Privacy Practices:

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Hear from our happy families

My husband and I came to Dominion Fertility due to our reoccurring miscarriages. We knew our doctor was the doctor for us. He was very friendly and immediately put us at ease. He’s very knowledgeable on the subject of miscarriage among other things and answered all our questions in detail. What I liked most was his confidence in helping us with our problem. He never gave up on us. I also appreciated the time he spent with us at every appointment. I never felt rushed or pressured during appointments. The nurses and office staff are also very friendly. The wait time to be seen what very short if not at all. There were a couple visits in fact where they saw me ahead of schedule if I arrived early. I would absolutely recommend Dominion Fertility to others.

Diane B

I just wanted to drop a quick note to talk about the wonderful experience we have had at Dominion through 2 natural cycle IVF treatments. My husband had sold medical equipment to almost every fertility center in the area, and chose Dominion based on the fact that they seemed the most professional and treated him the best, had a great lab and great people. We investigated natural cycle after reading about it, and after meeting with Dr. D. The first attempt we had success and now have a wonderful 19 month old. :-) started at age 36.We went back (at age 38) and I am turning 39 soon and got a successful embryo transplant the 3rd time. The first two we didn't make it to the transfer process. They treated us with alot of understanding and kindness and encouragement. I love the entire staff there, the entire place is filled with very loving kind people. I actually am just about to get released totally from blood monitoring at 9 weeks pregnant and I will miss them!! I brought my 19 month old in a few times with me so they could see the miracle they had a great hand in making! Thanks Dr D and everyone at Dom Fert!!

JM

5 Stars! They treated us very well, and helped us bring our son into the world.

Anonymous

The whole process is incredibly stressful and expensive, but if you want results Dr DiMattina is the best doctor. Initially I found his style difficult but he knows what he is doing and the results speak for themselves.

CS

Everyone I ever dealt with at Dominion was very professional, knowledgable, and caring. If someone did not know the answer to a question, they told me they would ask, they did, and they delivered an answer within a reasonable amount of time. Having everything in house was also a great convenience. After four FETs I had a baby. Unfortunately, I moved across the country and now I am dealing with a fertility clinic that is not very professional, not very knowledgable, and not very caring. I ask questions but get other non-applicable information in reply. Its frustrating as hell dealing with these new people (not all clinics will take embryos from another clinic so my hands are tied) and it only makes me miss Dominion Fertility even more. Dr. D is the best. He is no-nonsense and tells you like it is. I appreciated that so much! He knows his stuff and he gets the intended result. If you are a competent professional and you want to deal with other competent professionals this is the place.

Rachel W

My story is unusual since I have secondary infertility, and my age was seemingly the only issue. We did 2 rounds of DE with 1 clinic because they offered the best price, but both fresh and frozen cycles failed. We moved to another clinic and did a DE cycle which failed as well. We took a short break then decided to see Dr. DiMattina for 1 last try. He suggested we add genetic testing for the embryos and turns out only a couple were normal despite a young proven donor. We transferred 1 healthy embryo and I'm 10 weeks pregnant. Thank YOU!!!

Kelli M

In 2010, I was diagnosed with Polycystic Ovarian Syndrome. My GYN at the time told me that it would be likely I would never be able to have children because of this condition. The thought that my life would never see motherhood was heartbreaking, and even more so when I married my husband in 2011. At the time of my marriage my mother was dying from lung cancer, and we felt more compelled than ever to try to have a baby before she passed away. Well, she died just two short months after my wedding, and we still had not had any luck conceiving. So, we decided to hold off on getting pregnant for a short time. After about 6 months, I went to my GYN and she put me on Clomid. 6 months of Clomid still didn’t do the trick. Again, we decided that if it was going to happen, it would happen in its own time, but that is a hard resolution to live with. Almost three years passed with no luck. Finally, we came to Dominion Fertility. Our very first visit with them we felt reassured and confident that they could help us. They immediately scheduled initial tests to try to determine the source of our infertility. They knew I had PCOS, but they also told us that plenty of women who have POCS are able to have children and that there were ways to treat PCOS that would allow us to conceive. After the initial testing, we came back to see them and they reassured us that everything came back great. Just hearing them tell us that it should not be a problem to get us pregnant, took a huge burden off my shoulders. We immediately began treatment using ovulation induction and timed intercourse. Within one cycle we were pregnant! While I know these results may be uncommon, I also know that the Doctors knowledge, experience and attention to detail helped us get pregnant. Throughout the entire process, we knew we could count on them for this honest, professional opinion. We knew we could count on them to stay within the confines of our beliefs and speak candidly with us about expectations. We always felt reassured and informed with them. The nurses and staff are so friendly and understanding. They truly make you feel that you are important and that you are not just another patient coming through their door. The Doctors and nurses took the time to explain everything to us and to answer any questions we had. They provided us with lots of information on infertility treatments and what was available to us. I cannot thank Dominion Fertility enough for helping us to get pregnant. For so long I thought I was broken until I met them. I felt like I have to resolve myself to not being a mother. That feeling for a woman is probably one of the worst. Thank you, Dominion Fertility. We really appreciate your knowledge, honestly, friendliness, and hard work throughout this process, and we know that if we ever need you in the future, we can count on you.

Malinda K.

We are so grateful to Dominion and their Doctors. The staff was very responsive to my numerous questions and we felt comfortable with our treatment cycle. I'm due in a couple of weeks with a baby girl!

Ana

IVF is not easy but now that we have a beautiful baby boy we are so grateful.

Neeta

We went to DF after many failed attempts at another clinic. At first I didn't think the cycle recommended was going to work because my previous called for high doses of meds, and I thought we needed more eggs to be successful. Our situation proves quality is better than quantity, just entered my second trimester!

Carolina

We are so happy and grateful to Dominion Fertility for helping us have our baby. They are kind, patient, and very knowledgeable.

Brooke Z

I normally don't write reviews, but I felt it was necessary considering the bizarre negative ones I've seen on Yelp. DF is world's apart from any other fertility clinic we have worked with. We have been on this journey for 7 years so we have unfortunately had a lot of experience. I could write a book detailing how good our experience has been compared to the biggest clinic in DC area. Do thorough research and you will decide for yourself not to waste time and money elsewhere and just go directly to the best.

Wazma