Supplementary Fertility form

This form collects background information so the most relevant treatment can be given. If you do not want to answer any question please feel free to N/A or leave it blank you can still have Japanese Reiki, Facial or Maternity Reflexology, Needle Free Acupuncture or Ayurvedic Reflex Massage, Coaching & Yoga sessions. Please also fill in the General Consultation form as well. Thank you

Name

Date Of Birth

Your Age

Address

Phone Number

Mobile Number

Best Time To Call

Name and mobile number to contact in an emergency?

How many years in total have you been trying for a baby?

What cycle of IVF (other treatment?) are you on now?

Date of latest IVF Implantation if applicable?

Is there a medical reason for not getting pregnant before?

What health issues do you have at the moment that you want to tell me about?

What medical tests have you had so far and were the results ok?

Have you mentioned to your consultant or GP that you are going to have Reflexology, Japanese Reiki, Needle free Acupuncture or Ayurvedic treatments?

Yes No

Have you ever had a miscarriage

Are you still working?

Yes No

If yes what do you do?

Disclaimer:

I accept that the information provided above is a true and accurate reflection of my state of health and will tell the therapist if there are any changes to the above information. Information is destroyed after 8years in line with insurance guidelines and GDPR 2018.

Get In Touch

Paradise Clinic
Corner, High St & Paradise Rd
Kemnay
Aberdeenshire
AB51 5NB

Mobile: 07896 047 660
drjones@paradiseclinic.co.uk

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ADDRESS:
Paradise Clinic
Corner, High St & Paradise Rd
Kemnay
Aberdeenshire
AB51 5NB

CONTACT PHONE:
07896 047 660

E-MAIL ADDRESS:
drjones@paradiseclinic.co.uk

Supplementary Fertility form

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