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Patient name Date of birth MPI#MALE PATIENT: U.S. THIS FORM MUST BE COMPLETED BY ANY MALE PATIENT WHO WILL RECEIVE MEDICAL TREATMENT AND/OR EVALUATION. Patient Information DemographicsName (last,
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Fertility Centers of Illinois is a fertility clinic that offers a wide range of fertility treatments and services to help individuals and couples achieve their dream of having a baby.
Anyone who has received fertility treatment or services from Fertility Centers of Illinois is required to file.
To fill out Fertility Centers of Illinois, you must provide information about the treatments and services you received, as well as any relevant medical history.
The purpose of Fertility Centers of Illinois is to collect data on fertility treatments and outcomes in order to improve patient care and research in the field of reproductive medicine.
Information such as the type of treatment received, dates of treatment, outcomes, and any relevant medical history must be reported on Fertility Centers of Illinois.
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