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?* | |  |
| | |