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First Consultation Form (Female)

Basic Information

First Name*

Middle Name*

Last Name*

Day of birth/M/D/Y*

Height/ft*

Weight/lbs*

Relationship status:*

Present address*

Tel*

Email*

Emergency Contact*

Tel*

Medical History

Allergies *

Medication history *

Any prior hospitalizations*

Pregnancy History

How many times have you been pregnant

Pregnancy When How long to conceive Gender Is current partner the father Outcome
1
2
3
4
5
Pregnancy 1
When
How long to conceive
Gender
Is current partner the father
Outcome
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Previous IVF History

Date of procedure Protocol #of eggs obtained #of eggs mature #of eggs fertilized #day 3 embryos #day 5 embryos #embryos transferred Pregnancy outcome
Date of procedure
Protocol
#of eggs obtained
#of eggs mature
#of eggs fertilized
#day 3 embryos
#day 5 embryos
#embryos transferred
Pregnancy outcome
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Reproductive Health

At what age did you have the first menstruation/ Y.O*

How many days in between your periods/days*

When did your latest period start When did your latest period start/M/D/Y*

For how many days did you bleed/For how many days did you bleed/ days*

At what age did your mother experience her menopause?/Y. O*

Have you done any uterine tests?*
Is the result normal ?*

Relevant Areas

Are you interested in doing PGS/PGD for identifying genetic disorders?*
Are you interested in sex selection?*
Are you interested in the third party assisted reproduction?*
Do you smoke?*
Do you drink?*

I have filled out this form to the best of my knowledge and all details supplied by me are truthful and complete. I am aware that any falsehoods may lead to patient rejection by doctor; the medical institution is not responsible for any misrepresentations.

Signature:*

Date:*

YOUR FAMILY JOURNEY STARTS HERE

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Online customer service
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Customer service hotline

(626)360-3232
7 * 24 hours customer service hotline

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