Appointment Form

Appointment Form

PLEASE COMPLETE THE FOLLOWING FORM INCLUDING THE MEDICAL HISTORY SECTION. UPON RECEIPT OF THIS FORM, YOU WILL BE CONTACTED TO SCHEDULE AN APPOINTMENT.

New Patient Appointment Form

General Information

General Information cont'd

Your Partner

Female Patient Medical History

Please complete this form to the best of your knowledge. If there are any question you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment. The form will take some time to complete. if you have any questions or queries, please do not hesitate to contact us.

If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them.

Have you ever undergone an operation? (If so, please give details including the year).













Social History

Family History

Mental Health Questions

Menstrual History

Gynaecology History










Obstetric History

If the answer is yes, please provide any information you can below.

Pregnancy 1

Pregnancy 2

Pregnancy 3

Pregnancy 4

Pregnancy 5

Previous Treatment

If Yes Please Provide As Much Information As You Are Able To

Treatment 1

Treatment 2

Treatment 3

Treatment 4

Treatment 5

Male partner Medical History (If Applicable)

Fertility / Andrology

Social History

Mental Health Questions

Surgical History













Additional Comments

Your records are considered confidential and will not be released without your consent and signature.

I hereby authorise the Sims Fertility Clinic to release information to my GP and myself.

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