IVF Intake Form Please fill out the following questions to the best of your ability. If you require any assistance or are unsure how to answer, please contact us using the Contact Us link above and we'll be happy to help you out. Name* First Last Age*Date of Birth*Marital Status*MarriedIn a relationshipSingleYour partner's / spouse's name First Last Your partner's / spouse's ageYour partner's / spouse's date of birthAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Enter Email Confirm Email Phone*How would you prefer us to contact you?*EmailPhoneIs it OK for us to leave a voicemail on your phone if we can't reach you?*YesNoYour height*Your weight*Your blood pressure*Do you have any allergies? Please list them along with what kind of reaction you may have (If you know)What contraception do you currently use?*Please list all the medications you are currently taking. For each medication, please list the name, the dose, and the frequency. (One per line please)Please list any vitamins / supplements you may be taking. For each item, please list the name, the dose, and the frequency. (One per line please)Do you (or your partner) use recreational drugs?*YesNoIf you (or your partner) have used recreational drugs, please enter what substance(s) have been usedIf you have done an IVF cycle before, please enter the following information for each cycle you have completed (one per line please): IVF Centre, # Eggs Retrieved, # Embryos Transferred, # Embryos Frozen, # PGS/PGD Normal Embryos, OutcomeHave you tried IUI before?*YesNoIf you have tried IUI before, how many attempts?Has a sperm analysis been done?*YesNoHas a DNA Fragmentation been done?*YesNoHas any male factor issue with sperm been identified?*YesNoHow many times have you been pregnant?*How many live births?*How many vaginal deliveries?*How many C-section deliveries?*How many abortions have you had?*How many miscarriages have you had?*How many ectopic pregnancies have you had?*How many chemical pregnancies have you had?*Please list any complications related to the above pregnancies (if applicable)Please list any previous surgeries you have had in the past, when and any complications that may have occurred (one per line please)Please enter any clinical next steps / plans you have discussed with the doctorWill you sign medical consent forms to allow our IVF nurse to access all of your medical records for review?*YesNoHave you received any IVF funding for any procedures?*YesNoHas the doctor reviewed the risks / complications with you regarding the procedure?*YesNoAre you satisfied with the care you are receiving?*YesNoAre you looking for a second medical opinion?*YesNoDo you feel you have been an active part of your fertility plan? Please explain*Have you tried any of the following holistic procedures?* Acupuncture Chinese Herbs Osteopath Treatments Naturopath Treatments None of the above Are you being followed by any other specialists for any related or unrelated medical reasons?*YesNoIf yes, please list in detailHas an egg or sperm donor been considered or suggested by your fertility physician?*YesNoPlease list any further questions you may have (one per line please)What do you envision for your Support Plan with us?*Once the submit button is pressed the word "Processing" will appear. Your application has been submitted and Canadian Surrogacy Community will be in touch. Thank you for your submission.