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Pre-admission questionnaire

This is an easy and safe system enabling to consult your case with our specialist. After analysing your sent information our specialist will send you back a proposal of further procedure and therapeutical possibilities.

PovinnéRequired items

Basic information



Female patient:



Previous pregnancies

Previous partner

Please fill month/year to the yellow brackets.

Present partner

Please fill month/year to the yellow brackets.


Previous examination

Male patient:


Sperm examination

Results of 2 – 3 last sperm examinations.

Both patients:

Infertility history

Table 1: Insemination

Table 2: Artificial Fertilization

Table 3: Frozen embryo transfer

Please scan and send us with filled Questionnaire all of your previous examinations and treatment of infertility or bring these documents with you to first visit in our clinic.

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