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Obstetrics Gynecology – MD, MSC, MMSC, Phd – Fertility Specialist
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In Vitro Fertilization (IVF)
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IVF options for single women
Intra Uterine Insemination (IUI)
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Egg donation
Egg Freezing
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SVF Ovarian Rejuvenation treatment
Renovo2 – Reproductive Innovation
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Ovarian Rejuvenation
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Advanced Genomic Testing
Non-invasive prenatal testing
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Well Woman Check
Laparoscopy
Hysteroscopy
Colposcopy
Endometriosis
Polycystic Ovaries Syndrome – PCOS
Fibroids
Articles
News
Contact
Menu
About
Personal Profile
Vision
Why choose us
Tour the Center
Testimonials
Certifications
Travel
Fertility
IVF Treatments
Step by Step
In Vitro Fertilization (IVF)
Natural Cycle IVF
Natural Modified IVF
Mini IVF
IVF Sure
Frozen Embryo Transfer
IVF options for single women
Intra Uterine Insemination (IUI)
Fertility Counseling
Egg donation
Egg Freezing
Innovative Treatments
SVF Ovarian Rejuvenation treatment
Renovo2 – Reproductive Innovation
Fortasc 1
Ovarian Rejuvenation
Surrogacy
Genetic Controls
KIR-HLAC genotyping test
Advanced Genomic Testing
Non-invasive prenatal testing
Endometrial Receptivity Map
Gynaecology
Well Woman Check
Laparoscopy
Hysteroscopy
Colposcopy
Endometriosis
Polycystic Ovaries Syndrome – PCOS
Fibroids
Articles
News
Contact
Home
»
Medical Record of the Patient
Medical Record of the Patient
Please complete the following form.
Step
1
of
5
- Personal Info
20%
1st Visit/ Medical Record of the Patient
Please fill out your personal Information
Date
*
YYYY dash MM dash DD
Referral Doctor
Step 1 - Woman - Your personal Information
Please fill out your personal Information
First Name
*
Last Name
*
Date of Birth
*
YYYY dash MM dash DD
Address
Postal Code
City
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Occupation
Phone
*
Email
*
I.D/Passport Number
Marital status
Single
Married
Divorced
Widowed
Step 2 - Man - Your partner's Information
Please fill out your partner's Information
Partner's First Name
Partner's Last Name
Partner's Date of Birth
YYYY dash MM dash DD
Partner's Address
Partner's Postal Code
Partner's City
Partner's Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Partner's Occupation
Partner's Phone
Partner's Email
Partner's I.D/Passport Number
Step 3 - Woman - Your medical information
Please fill out some of your personal medical information
Have you ever been pregnant?
No
(if Yes, please mention)
How long have you been having unprotected sexual contact?
Is your period regular?
Yes
(if no, please mention ex. menopause)
Do you have any kind of medical condition? (illness, syndrome, disability, etc)
No
(if Yes, please mention)
Are you taking any medicine?
No
(if Yes, please mention)
Do you have any allergies/to medication?
No
(if Yes, please mention)
Have you undergone any operations in the past?
No
(if Yes, please mention)
Have you ever been diagnosed with a gynecological issue?
No
Uterine Fibroids
Endometriosis
Polycystic Ovaries
Polyps
Pelvic inflammation
Have you ever made an IVF attempt?
No
(if Yes, please mention in chronological order and the outcome)
Do you have family history of a medical condition or cancer?
No
Yes, please mention the degree of relationship and the condition/cancer)
Do you smoke?
No
Yes, please mention Cig./per day & Number of years
Any other overconsumption (ex. Alcohol) or substance abuse ?
No
Yes
Height (cm)
Weight (kg)
Blood group
Notes
Ιn case of egg donation
Eye colour
Hair colour
Skin color
Step 4 - Man - Your partner's medical information
Please fill out some of your partner's medical information
Have you ever become a parent in the past?
No
Yes
If yes, please specify how many times.
Do you have any kind of medical condition? (illness, syndrome, disability, etc)
No
(if Yes, please mention)
Are you taking any medicine?
No
(if Yes, please mention)
Do you have any allergies?(if Yes, please mention )
No
(if Yes, please mention)
Have you undergone any operations in the past?
No
(if Yes, please mention)
Have you ever had a problem with your reproductive organs?
No
(if Yes, please mention)
Do you have family history of a medical condition or cancer?
No
(if Yes, please mention the degree of relationship and the condition/cancer)
Do you smoke?
No
(if Yes, please mention Cig./per day & Number of Years
Any other overconsumption (ex. Alcohol)?
No
Yes
(if Yes, please mention)
Height (cm)
Weight (kg)
Blood group
Notes
Ιn case of sperm donation
Eye colour
Hair colour
Skin color
Phone
This field is for validation purposes and should be left unchanged.
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