American fertility medical center
Home> Patient Resources> First Examination Eorm

First Consultation Form (Male)

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*

Reproductive Health

Have you done any sperm analysis?*
Sperm Analysis result normal?*
Do you have any children?*

Relevant Areas

Are you interested in doing PGS/PGD ?*
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

Request An Appointment

Customer service

Online customer service
The respect customer, we wholeheartedly at your service 24 hours

Select the following customer service online communication right away:

Customer service hotline

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

Return to the top