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

Event code

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.

I agree to the Sims IVF Privacy Policy

General Information

Patient First Name

Patient Last Name

Gender at birth

Gender you identify as:

Date of Birth

Full postal address

Personal email address

Home telephone number

Ok to leave a message?

Work telephone

Ok to leave a message?

Mobile phone

Ok to leave a message?

General information cont.

Nationality

Occupation

PPS Number

DPS number

Known allergies

GP name

GP Address

Do you have health insurance?

Name of insurance company

If you are with Vhi, please enter your policy number

Do you have a medical referral to Sims?

Name of referring doctor

Have you already been issued with an appointment for initial consultation?

If you were not referred by a doctor please indicate how you heard about Sims IVF?

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. Please enter weight in stone or kg.

Height

Weight

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

Operations

Are you currently on any medications?

How long have you been trying to conceive?

Have you used contraception before?

Are you currently attending a medical doctor or being treated for an illness or medical condition?

Have you had any illness or been treated for a medical condition in the past?

Do you have any general medical complaints at present?

Are you currently using any non fertility medication?

Previous Treatment

Have you had previous fertility 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.

Height

Weight

Are You Currently On Any Medications?

Do You Have Any General Medical Complaints At Present

Have You Had Any Illnesses Or Been Treated For Any Medical Condition In The Past

Are You Currently Attending A Medical Doctor Or Being Treated For A Medical Condition

Your Partner

Do you have a partner?

Your Partner

Partners First Name

Partners Last Name

Partners gender

Partners Date of Birth

Partners email address

Partners phone

Ok to leave a message?

Partners occupation

Partners known allergies

Partners GP name

Partners GP address

Do you have health insurance?

YesNo

If yes, which health insurance company are you with?

If with Vhi, please input policy number

Female Partner Medical History

Height

Weight

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

Operations

Are you currently on any medications?

How long have you been trying to conceive?

Have you used contraception before?

Are you currently attending a medical doctor or being treated for an illness or medical condition?

Have you had any illness or been treated for a medical condition in the past?

Do you have any general medical complaints at present?

Are you currently using any non fertility medication?

Female Partner Obstetric History

Have Been Pregnant Before

Female Partner Previous Treatment

Have you had previous fertility treatment

Male Partner Medical History

Height

Weight

Are You Currently On Any Medications?

Do You Have Any General Medical Complaints At Present

Have You Had Any Illnesses Or Been Treated For Any Medical Condition In The Past

Are You Currently Attending A Medical Doctor Or Being Treated For A Medical Condition

Additional Comments

Any additional comments

Do you have any special requirements you would like to make us aware of?

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.

Please indicate yes or no