Patient Registration Form Please fill in the form completely to help us better. 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