NFC - Success Rates

Pregnancy and Delivery Results Report Form

We hope your pregnancy and delivery have gone well. We need to confirm information concerning your delivery for our records, and to be in compliance with the rules and regulations under which we practice.

We are required to report IVF pregnancies to the Centers for Disease Control and Prevention (CDC) in accordance with The Fertility Clinic Success Rate and Certification Act of 1992, which monitors assisted reproductive technology (IVF) programs. It requires the identification of all laboratories and treatments that involve manipulation of human eggs and embryos and the reporting of pregnancy success rates achieved by such programs.

Please take a moment to answer the following questions.

Your Name:

First Name

Last Name

If we have any questions about the information you submit, may we contact you by email? If so, please provide your email address.

email address

If you would rather be contacted by telephone, please provide a daytime telephone number with area code.

Daytime phone number

Type of procedure provided by NFC that resulted in pregnancy:

If "other" was selected, please explain:

What was the approximate date of the procedure (month/year)?

Enter the date of delivery :

-- mm/dd/yy

Delivery of:

Birth weight(s)?

Baby 1: pounds ounces

Baby 2: pounds ounces

Baby 3: pounds ounces

Problems with your pregnancy ?

Method of delivery

Problems with child(ren)?

Sex of child(ren):

Baby 1

Baby 2

Baby 3

Additional information you would like to share with us. (This information will not be reported to the CDC.)

Thank you for your timely response. We look forward to hearing about your family.

Nashville Fertility Center 345 23rd Ave. N., Ste. 401, Nashville, TN 37203 (615)321-4740 Fax (615)320-0240