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Female patient registration form

Please complete the form below. We will process your data in accordance with our privacy policy.

If you prefer, you can download the female patient registration form. This must be filled in, scanned, and returned to info@fertility-academy.co.uk.

Please note: If you are having trouble filling in the forms, or have any questions, please call 020 7224 1880 or email us.

Female patient registration form

Please complete the form below. We will process your data in accordance with our privacy policy.

If you prefer, you can download the female patient registration form. This must be filled in, scanned, and returned to info@fertility-academy.co.uk.

Please note: If you are having trouble filling in the forms, or have any questions, please call 020 7224 1880 or email us.

    Fields marked with * are compulsory and required by the Human Fertilisation & Embryology Authority (HFEA). If these fields are not completed, treatment cannot commence.

    Your Details

    YesNo

    YesNo

    YesNo

    Please note UK government advise couples not to conceive within 8 weeks of travel to Zika affected areas.

    YesNo

    YesNo


    Emergency Contact Detail


    Obstretic History


    Cause Of Infertility / Reason For Treatment (More than one may apply)

    Tubal disordersEndometriosisUterine ProblemsOvarian FailureAvoidance of genetic disorderNo male partnerOther


    Ethnic Group

    Please select the option that best describes your ethnic group. If you are unsure, please select ‘Other’. *

    White

    BritishIrishEastern EuropeanOther

    Mixed / Multiple ethnic groups

    White and Black CaribbeanWhite and Black AfricanWhite and AsianOther

    Black / African / Caribbean / Black British

    CaribbeanAfricanOther

    Asian / Asian British

    IndianPakistaniBangladeshiChineseJapaneseOther


    Our Privacy Policy can be accessed on our website.

    We confirm that the information given above is true and accurate. *

    We confirm that I/We have read and understand The Fertility and Gynaecology Academy’s Privacy Policy. *

    We confirm that I/We have read, understand, and agreed to The Fertility and Gynaecology Academy’s Terms & Conditions and Complaints Policy. *

    We confirm that I/We must bring hard copies of your photo ID to our consultation in order to be registered as a patient. *

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