Fertility Expert Advice and Quote Form:-
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are required.
From
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Africa
Asia
Australia
Europe
Middle East
North America
South America
Other
Title
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Mr.
Mrs.
Ms.
Miss.
Dr.
Prof. Dr.
Master.
Full Name
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Date of Birth (mm/dd/yyyy)
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Street Address
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City
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Country
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Phone
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Email
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Client Type
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Please Select
New Client/Patient
Returning Client (Existing Patient)
Duration of Infertility
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(Since how long you have been trying but no success)
Previous Investigations:
(If applicable)
General health tests
Thyroid tests
Hormonal tests
(FSH (Follicle-stimulating hormone), AMH (Anti-Mullerian hormone),
LH (Luteinizing hormone), PRL, E2, TSH (Thyroid-stimulating hormone), Testosterone)
Tubal patency test
(HSG, Laparoscopy, Sonohysterography, Hysteroscopy)
PGD/PGT
(Preimplantation genetic diagnosis) (Pre-Implantation Genetic Testing)
USS
(Pelvic ultrasound)
Semen test
Others
(Please explain in the text box above)
None of Above
Previous Treatments:
(If applicable)
(What treatement has your doctor/specialist suggested?)
Any Operation
Ovarian Stimulation
IUI
IVF
ICSI
None of Above
Treatemnt Seeking for:
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IUI
(intrauterine insemination)
IVF
(in vitro fertilisation)
ICSI
(intracytoplasmic sperm injection)
PGD/PGT
(preimplantation genetic diagnosis) (pre-implantation genetic testing)
Sex Related
(male/female sex related issue)
Others
(not mentioned above)
Your Recommendations
(need your recommendations)
Travel & Living Expense
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Include travel and living expense in the package
Do not include travel and living expense
Upload Reports (optional)
Terms of Use
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