Home - Texas Fertility Center Forms

Patient Information

Patient Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Marital Status

Insurance Provider*

All HMO plans and some other specific plans (i.e. Healthselect) require a referral from a Primary Care Physician before a patient can be seen at Texas Fertility Center. We strongly encourage patients to check with their insurance company to confirm whether or not a referral is required. Also, Texas Fertility Center does not participate in any government-sponsored health plans such as Medicare, Medicaid, MAP, or Tricare. Due to the changes with insurance participation in the Affordable Healthcare Act, as of January 1, 2017, TFC will not be contracted with any Marketplace health plans.

Other Insurance Provider*

Insurance ID Number

Insurance Group Number

Do you have a partner or a spouse?

Yes
No

Partner's Name*

First Last

Partner's Date of Birth*

Partner's Insurance Provider*

Partner Insurance ID Number

Partner's Insurance Group Number

Please Provide Physician's Name

Do You Have a Doctor Preference*

Thomas Vaughn - Please Select Office*

North Austin Office - 6500 N Mopac

Kaylen Silverberg - Please Select Office*

North Austin Office - 6500 N Mopac

Lisa Hansard - Please Select Office*

North Austin Office - 6500 N Mopac
Round Rock - 16040 Park Valley Drive
South Austin - 5000 Davis Lane

Anthony Propst - Please Select Office*

North Austin Office - 6500 N Mopac
Round Rock - 16040 Park Valley Drive

Erika Munch - Please Select Office*

San Antonio - 18707 Hardy Oak Blvd

Susan Hudson - Please Select Office*

New Braunfels - 705 Generations Dr

Allison Petrini - Please Select Office*

South Austin - 5000 Davis Lane

Amy Schutt - Please Select Office*

North Austin Office - 6500 N Mopac

Sarah Gavrizi - Please Select Office*

North Austin Office - 6500 N Mopac

Madeline Kaye - Please Select Office*

North Austin Office - 6500 N Mopac

I would be interested in a video consultation*

Yes
No

How Did You Hear About Us?

Comments

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Thank you for contacting TFC.

If you are an established patient, please contact our office during business hours for assistance. Our number is (512)451-0149.

Each patient’s medical, financial and insurance situation is unique. Please schedule an appointment to learn more about the cost of fertility treatment for you.

Thank you for your interest in becoming a sperm donor. However, Texas Fertility Center is not a sperm bank and does not accept sperm donations.

Patient Information