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Please complete the following form including the medical history section. Upon receipt of this form you will be contacted to schedule an appointment.

***€1000 off IVF or ICSI cycle in our Dublin clinics, limited time only, terms and conditions apply. See Ts &Cs here.


If you are taking any form of hormonal contraception we recommend you book in for an initial consult instead of our fertility package so one of our Doctors can tailor your investigation plan as hormonal contraception can impact test results



Privacy Policy

I have read and understood the Sims IVF Privacy Policy and I agree to the processing of my personal data as per this policy. I am aware that I can contact dpo@virtushealth.ie if I have any queries regarding the processing of my personal data or if I wish to withdraw consent for this processing.

General Information














General information cont.















Female Patient Medical History

Please complete this form to the best of your knowledge. If there are any question you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment.

 If you have any questions or queries, please do not hesitate to contact us.

If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them.

BMI and Height information is required. This information will be re-confirmed in Clinic.



Have you ever undergone an operation? (If so, please give details of all operations including the year).








Previous Treatment


Male Medical History

Please complete this form to the best of your knowledge. If there are any questions you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment. 

If you have any questions or queries, please do not hesitate to contact us. 


If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them. 






Your Partner


Your Partner















Female Partner Medical History



Have you ever undergone an operation? (If so, please give details of all operations including the year).








Female Partner Obstetric History


Female Partner Previous Treatment


Male Partner Medical History 







Additional Comments



Authorisation

Your records are considered confidential and will not be released without your consent and signature.

I hereby authorise the Sims Fertility Clinic to release information to my GP and myself.