Name
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Surname
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E-Mail
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Birthdate (woman)
Country
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United Kingdom
Afghanistan
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Zimbabwe
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Phone number
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Your situation
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Couple
Same Sex Couple
Single
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What treatment are you interested in?
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Artificial Insemination
IVF/ICSI
Reception of donor eggs
Eggs Cryopreservation
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Sperm
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Partner
Donor
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I HAD PREVIOUS FERTILITY TREATMENTS
How did you hear about us?
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Google search/Internet
Fertility Website
Friends
Doctor/Gynecologist
Others
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DO YOU HAVE ANY PATHOLOGY?
Endometriosis
Polycystic ovaries
Ovarian faiure
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ANOTHER PATHOLOGY NOT DESCRIBED ABOVE
DOES YOUR PARTNER HAVE ANY PATHOLOGY?
low sperm count
azoospermia
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ANOTHER PATHOLOGY OF YOUR PARTNER NOT DESCRIBED ABOVE
Other information
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I HAVE READ AND ACCEPT THE PRIVACY POLICY
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