Patient Registration Form

Your name *

Date of Birth*

Patient's Phone Number*

E-mail Address of the Patient*

Partner's Name *

Partner's Date of Birth*

Phone Number of your Partner*

E-mail Address of your Partnert*

Infertility Diagnosis (please tick all that apply)* Problem with egg quality Problem with fallopian tubes Previous tubal ligation (tubes tied) Uterine abnormality Problem with ovulation PCO – Polycystic Ovarian syndrome Premature ovarian failure Endometriosis History of multiple miscarriages Problem with partners sperm ( male factor infertility) Previous hysterectomy Unknown infertility Cancer diagnosis and desire to preserve fertility Other IF you checked other please describe:*

Treatment that you are seeking with IVF Experts International team (please tick all that apply)* IVF using my partners sperm (IVF) IVF using donors sperm (Sperm donation/SD) Use of Donors Eggs (Egg Donation/OD) Surgical extraction of my partners Sperm (TESA/TESE/PESA) Pre-implantation genetic diagnosis/screening (PGS/PGD) Gender selection (CS) Tandem Cycle Use of gestational carrier (surrogate mother) Plan to freeze eggs STEM CELL Other IF you ticked other please describe:*

Previous infertility treatments

1 Year

Infertility Treatment

Result

2 Year

Infertility Treatment

Result

3 Year

Infertility Treatment

Result

4 Year

Infertility Treatment

Result

Do you have any Allergies to Medication?YesNo If YES please list medication and Reaction:*

Are you using any medications?YesNo If YES please list the medication:*

Do you or your relatives have any CHRONIC DISEASES? Asthma Hyper tension (HT) Thyroid Disorder Other Diabetes No If you ticked other please describe:*

Do you smoke?YesNo

Have you ever had an operation:YesNo Please list previous surgeries:*

Last Menstruation Period Date:*

Previous Fertility Testing* AMHLHFSH TSHFT4Karyotype Blood GroupAnti TPOPRL VIT D3HSGSHS H/SL/S Please Type The Results*

Male* T.TestDHEA17OHP KaryotypeBlood GroupSperm Test VolumeCountProgressive Motility Morphology Please Type The Results*

Attach your results