Male 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: 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]