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Kinderwunsch Centrum München Terminvereinbarung

Step 1 of 4 - Female data

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Female Patient

Date of Birth(Required)

Type of Insurance(Required)
Insurance Subsidy

Partner/in

Date of Birth(Required)
Gender(Required)

Type of Insurance(Required)
Insurance Subsidy

Medical Data Part 1

Are you married to each other?(Required)
Do you already have children together?(Required)
Please enter a number greater than or equal to 0.

Female

Please enter a number from 10 to 999.
Height measured date(Required)
Please enter a number from 10 to 999.
Weight measured date(Required)

Male

Please enter a number from 10 to 999.
Height measured date(Required)
Please enter a number from 10 to 999.
Weight measured date(Required)

How long have you been trying to get pregnant? ( this means: cycles with unprotected sexual intercourse)

Please enter a number from 1 to 99.

DD slash MM slash YYYY
Please enter a number from 1 to 99.

If hormone values have already been taken, please tell us the values determined

DD slash MM slash YYYY
DD slash MM slash YYYY

Have you already had preliminary diagnostic tests or treatments in another fertility center?(Required)
Is there an up-to-date spermiogram? (Not older than 12 months)(Required)
DD slash MM slash YYYY

Referring/treating OBGYN:

Referring/treating urologist:

Interpreter

How did you find out about us?(Required)

By submitting this appointment request form, I consent to the KCM storing the personal information provided and using it in the process of scheduling an appointment.

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