Online Consultancy Form
  1. Please complete my consultancy form below with as much information as possible and I will respond within 24-hours.

    Please note that completing the form does not commit you to anything but is simply for the purpose of me being able to better assist you.

    Items marked with (*) are required.
  2. Patient 1 Name on Passport(*)
    This information is required
  3. Nationality(*)
    This information is required
  4. Patient 1 Passport No.
    Invalid Input
  5. Patient 2 Name on Passport(*)
    This information is required
  6. Nationality(*)
    This information is required
  7. Patient 2 Passport No.
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  8. Country of Residence(*)
    This information is required
  9. State
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  10. Email Contact (*)
    Please enter a valid email address
  11. Intended Treatment(*)
    Some information is required
  12. How long have you been trying to get pregnant?
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  13. Reason given for infertility?
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  14. Month treatment required?
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  15. Female History
  16. Date of Birth(*)
    / / Invalid Input
  17. Height
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  18. Weight
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  19. Date of Last Period:
    / / Invalid Input
  20. Days in cycle?
    Invalid Input
  21. Details of any fertility tests:
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  22. Number of miscarriages/abortions:
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  23. Number of previous live births:
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  24. Previous Fertility Treatments:
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  25. Details of relevant medical history:
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  26. Current Medication:
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  27. Male Partner History
  28. Date of Birth(*)
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  29. Height
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  30. Weight
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  31. Previous pregnancies with partner(s):
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  32. Date of last sperm analysis:
    / / Invalid Input
  33. Sperm count:
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  34. Motility:
    Invalid Input
  35. Morphology:
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  36. Current Medication:
    Invalid Input
  37. Invalid Input