Cork New Patient Form 2024
Which treatment options are you interested in?
Fertility Testing
Insemination (IUI)
Egg Freezing
IVF/ICSI
PGT-A (Preimplantation Genetic Testing for Aneuploidy: PGT-A is a specialised diagnostic technique used to test embryos for chromosomal abnormality)
Shared Motherhood (for same-sex female couples)
Egg Donation
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 (Please
use full legal name per passport)
Patient Last Name (Please
use full legal name per passport)
Gender at birth
Please select...
Female
Male
Gender you identify as:
Date of Birth
Full postal address
Personal email address
Mobile phone
General information cont.
PPS Number
Name of GP
GP's address
BMI and Height information is required. This information will be re-confirmed in Clinic. Please enter weight in stone or kg.
Height
Weight
Do you have health insurance?
Please select...
Yes
No
Name of insurance company
If you are with Vhi, please enter your policy number
Previous Treatment
Have you had previous fertility treatment
Please select...
Yes
No
Your Partner
Do you have a partner?
Please select...
Yes
No
Your Partner
Partners First Name
Partners Last Name
Partners gender
Please select...
Male
Female
Partners Date of Birth
Partners email address
Partners phone
GP Name
GP's address
Height
Weight
Do you have health insurance?
Please select...
Yes
No
If yes, which health insurance company are you with?
If with Vhi, please input policy number
Female Partner
Previous Treatment
Have you had previous fertility treatment
Please select...
Yes
No
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
Please select...
Yes
No
Contact Information