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FertilityCare assessment / further information form

Please complete SECTIONS 1 and 2 for treatment as appropriate
(infertility treatment is available to married couples only).

All required fields are marked with *

In taking the time to complete and send the assessment form you are providing us with the information we need to be able to advise you on whether or not you would benefit from the LIFE FertilityCare programme. Any medical information you give us regarding your health and your personal details will be used for assessment purposes only and kept strictly confidential. LIFE FertilityCare conforms to the UK Data protection Act 1998 and the Care Quality Commission regulations.

NOTE: Treatment can generally only be accessed by residents of the United Kingdom - if you reside outside the UK you can find out more about this treatment from the following websites: for United States of America visit naprotechnology.com; for Australia visit fertilitycare.com.au; for Ireland visit fertilitycare.ie

PLEASE FILL IN AS MUCH INFORMATION AS YOU CAN

SECTION 1 - General Assessment (All enquiries complete section 1)

Check all relevant box(es)

SECTION 2 - Procedures and Treatments

NB: This section must be completed for all enquiries regarding fertility treatment - we need this information in order to make an assessment.

Which if any, of the following procedures have been carried out?

Click the relevant checkbox(es) below and give dates and further information if relevant.

Please summarise your general gynaecological/obstetric history

Please check the details of the form thoroughly, then click submit to send us your application form.