Female Patient Registration Form 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 Title * —Please choose an option—MrMrsMissMsDrOther Current Forename(s) * Current Surname * Surname at birth (if different) Marital Status: * —Please choose an option—MarriedCo-habitSingleWidowedCivil Partnership If not married or in civil Partnership, are you married to someone else? YesNo Date of birth * Home Telephone: Mobile Telephone: * Work Telephone: Email: * Current Home Address: Town of birth NHS/Passport/ID number Country of issue Occupation: Do you have a disability? Have you travelled from abroad? * YesNo Do you require a chaperone? *YesNo Insurance company: GP details: GP telephone: GP address: Please note UK government advise couples not to conceive within 8 weeks of travel to Zika affected areas. Have you travelled in a Zika virus affected area in the last six months? (If unsure please ask our staff for a list or check www.gov.uk website) * YesNo Have you travelled in an Ebola virus affected area in the last six months? (If unsure please ask our staff for a list or check www.gov.uk website) * YesNo Where did you hear about us? * —Please choose an option—GP/clinicianFriend/familyGoogle searchSocial mediaWebinarSupport forum (for example, Fertility Friends)Other Emergency Contact Detail Contact name: Home telephone: Mobile: Relation to patient: Work telephone: Obstretic History Total number of previous natural pregnancies: Total number of natural live births: Total number of previous IVF pregnancies: Total number of IVF live births: Total number of Donor Insemination pregnancies: Total number of Donor Insemination births: Duration of infertility: 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. * [Back to patient registration forms]