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:


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?: *