International Patient Intake Form

Assisted Reproductio...

International Patient Intake Form Send Link

International Patient Intake Form

Please complete the following information and include a CORRECT email address. We are unable to process this form without a valid email address. Once completed, click once on the “SUBMIT” button at the bottom of the page. The GRS International Patient Coordinator will contact you via email after reviewing your form.

What is YOUR First & Last Name (This field is required.)

Street Address

Phone number with international area codes if needed

Fax number if applicable

Email address (This field is required)

Female partner (wife) date of birth

Male partner (husband) date of birth

How long have you been trying to conceive?
(Enter "0" if you are not trying.)

How many times have you been pregnant?
(Include miscarriages, ectopics & terminations)

How many times have you delivered a live born baby?

How many pregnancies has the male partner fathered?

Please describe the female partner’s previous pregnancies. Enter the year they occurred.(Year) How many weeks did you carry the pregnancy(Duration)? Did you deliver (DEL), have a cesarean (CS), miscarriage (SPAB) ectopic pregnancy (ECT) or terminate the pregnancy (TAB)? Enter the appropriate outcome. Did you have fertility problems (Infertility)? Enter Y/N. And, did your present partner father that pregnancy (Present)? Enter Y/N.

Year	Duration (wks)	Outcome (DEL, CS, SPAB, ECT, TAB)	Infertility (Y/N)	Present Male (Y/N)

Where do you live? (Country)

Where did you hear about Georgia Reproductive Specialists?

Do you have a contact person in the United States who will help with travel, lodging, language, etc. arrangements if necessary if you decide to travel to the US for treatment? Please supply the name and phone number for that person.

Reproductive Medicine Problems
(Check each item that applies)

Endometriosis
Pelvic Adhesions
Previous ectopic pregnancy
Absent/blocked fallopian tube(s)
Absent/irregular periods
Abnormal semen analysis/male factor
Recurrent pregnancy loss
Premature menopause
Abnormal postcoital test
Fibroid tumors
PMS
Breast discharge
Abnormal FSH, LH, Prolactin, or progesterone levels
Immune abnormalities
Other (please describe)