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?:
* | | |
| | |