New Patient Qualification Form - Adonis Fertility International

NEW PATIENT QUALIFICATION FORM

When it comes to the fertility journey, there is no single solution that fits all, because every situation is very unique. To ensure our fertility specialists recommend the best program for you, please fill out this form to the best of your knowledge. If you have any questions, do not hesitate to contact us at info@adonisfertilityintl.com or +1 719-210-1661.

You are worthy of your dream of a baby! We are so proud of you for not giving up and taking the next step. We believe in you and in your dream.

Step 1 of 7

GENERAL INFORMATION
Married Couple*
- Yes
- No
Preferred Start of the Program (month, year)*
Yes, I agree to Terms of Use and Privacy Policy*
- I Agree
Terms Of Use & Privacy Policy
Patient 1 (woman)
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Country Of Citizenship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Cell Phone*
Home Phone
Blood group, Rh-factor
Patient 2 (man)
Name
First Last
Date of Birth
MM slash DD slash YYYY
Email
Cell Phone
Home Phone
Blood Group, Rh-factor

Medical Information
Please summarize your past experience as much as you can. At the end of the form, you will also find opportunity to download the supportive documentation.
Type of infertility (previous diagnosis)
Previous Fertility Treatment Experience?*
- Yes
- No
If yes, total quantity of previous ART Programs
Number of IUI
Number of IVF

Information about each IVF program
Click next if IVF is not applicable to your situation
IVF Date 1
IVF 1 Schema of Stimulation
Name of medicines and dosage, duration of stimulation in days
Quantity of follicles that were punctured
Quantity of oocytes that were received
Quantity of embryos
Quantity of embryos that were transferred
IVF 2 Date
IVF 2 Schema of Stimulation
Name of medicines and dosage, duration of stimulation in days
Quantity of follicles that were punctured
Quantity of oocytes that were received
Quantity of embryos
Quantity of embryos that were transferred
IVF 3 Date
IVF 3 Schema of Stimulation
Name of medicines and dosage, duration of stimulation in days
Quantity of follicles that were punctured
Quantity of oocytes that were received
Quantity of embryos
Quantity of embryos that were transferred
IVF 4 Date
IVF 4 Schema of Stimulation
Name of medicines and dosage, duration of stimulation in days
Quantity of follicles that were punctured
Quantity of oocytes that were received
Quantity of embryos
Quantity of embryos that were transferred

Family Anamnesis
Did somebody among your relatives from female or male side have infertility or miscarriage(s)?*
- Yes
- No
If yes, please include the details.
Do you have any relative (blood) connection in your couple (between man and woman)?*
- Yes
- No
If yes, please clarify.
Did somebody among your relatives have genetic disease?*
- Yes
- No
Please provide the details.
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 7

GENERAL INFORMATION

Patient 1 (woman)

Patient 2 (man)

Your Vision for the Program

Medical Information

Information about each IVF program

Patient 1 (woman)

Patient 2 (man)

Family Anamnesis