Electronic record

To be able to help you the best way we kindly ask you to fill-in as much as possible of the below questions. It there are any questions you cannot answer we can talk about it when we have the initial conversation.

Contact data

First name*
Last name*
Date of birth/Civil reg. no.*
Address*
Postal code*
Town/City*
Country*
Phone number
Mobile*
E-Mail*
Repeat email *
Skype name
Do you have a partner/spouse*
Partner’s firstname*
Partner’s last name*
Partner’s Date of birth*
Partner’s address*
Partner’s e-email*
Repeat email *
Partner´s gender*

General information about you

What treatment are you looking for*
Which type of work do you have? – important for us to know in relation to pregnancy
Are you suffering from, physical or mental illness*
Do you have any gynecological disorders? (Fibroma, endometriosis or PCO)*
Are you taking any medication? (Inclusive psychotropic medication or painkillers)*
- which
Have you been examined by a gynecologist for fertility*
Do you know the reason for your infertility*
- To what
Are your periods regular*
How many days are your cycle? (e.g. 28 days)
Have you been pregnant
Your height in cm*
Your weight in kilograms*

Blood tests and other examinations

If you have taken any of these tests, we kindly ask you to e-mail us a copy of the results – if possible before the initial conversation: AMH, TSH, anti-TPO, FSH, LH, Estradiol, AFC (follicle scan), HSU/HCG (examination of your fallopian tubes)

Sperm for the treatment

Are you going to use sperm from a donor, from your partner or from a known donor e.g. a friend
Are there any other relevant information you want to share with us? – please write here

Declaration

I/we confirm that I/we have received written information (from website or forwarded by Vitanova) on fertility treatment, and that the information I/we have provided is true and correct.

Do you agree with the above declaration?*