Register for Consultation

Please fill in the below fields carefully and accurately, as the doctor's advice will be based on the the information you submit here.

Basic Information

female

Male/Partner

Health History

health history

Female Partner

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Male Partner

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Family History

Are there any medical or genetic conditions in your family? Please provide details:

Social History

Female Partner

Male Partner

Menstrual History (Female)

Are your periods regular?

Yes No

Are are your periods painful?

Yes No

Please select last three months period dates (Start to End)

Fertility History

Fertility history for current relationship

Please describe in full detail

I confirm that the above information is correct and understand that it will be used by the doctor to provide a provisional treatment plan and timeline. I understand that the doctor may have to see us in person and additional investigations may be required before the final treatment plan is decided upon.

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