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Patient Intake Form

Patient Disclaimer

By using the Bliss IVF Fertility & Andrology, you agree to abide by the terms and conditions posted at our website www.blissivf.com including particularly the terms and conditions described below:

CONSULTATIVE SERVICE

The service provided through the Bliss IVF is different from the diagnostic services typically provided by a physician. The Bliss IVF Center providing this service will not have the benefit of information that would be obtained by examining you in person and observing your physical condition. Therefore, the physician may not be aware of facts or information that would affect his or her opinion of your diagnosis. BY DECIDING TO ENGAGE THIS SERVICE, YOU ACKNOWLEDGE AND AGREE THAT YOU ARE AWARE OF THIS LIMITATION AND AGREE TO ASSUME THE RISK OF THIS LIMITATION.

By requesting remote second opinion, you acknowledge and agree that:

The diagnosis you will receive is limited and provisional is not intended to replace a full medical evaluation or a face-to-face visit with a physician;

Bliss IVF Center does not have important information that is usually obtained through a physical examination; and,

The absence of a physical examination may affect the Bliss IVF Center ability to diagnose your condition, disease or injury.

BY ENGAGING OUR SERVICES,YOU ACKNOWLEDGE AND AGREE TO ASSUME THE RISK OF THESE LIMITATIONS.YOU FURTHER UNDERSTAND THAT NO WARRANTY OR GUARANTEE HAS BEEN MADE TO YOU CONCERNING ANY PARTICULAR RESULT OR CURE OF YOUR CONDITION.

Patient History Form

Wife History Form

Years.

Years. (i.e Regular Relation Without Anykind Of Contraception)

Regular Irregular

Normal Scanty Heavy

[i.e.0,1,2,3].

Conceived Naturaly Conceived With Tretment

Vaginal(Normal) Cesarean Section

Yes No

If Yes than

Yes No

Diabetes Hypertension Thyroid Cardiac Respiratory

Yes No

Hysteroscopy Laparoscopy Laparotomy Others

Name of Surgery: , Year

Diabetes Hypertension Thyroid Cardiac Respiratory

Patient History Form

Husband History Form

Yes No

Ejeculation Difficulty Pain During Intercourse Decreased Desire Any Other

Alcohol Drinking Cigarette Smoking Tobacco Chewing

Diabetes Hypertension Thyroid

IUI Treatment History

YearHospitalResultSelfIf Donor

IVF Cycle

YearHospitalFresh CycleFrozen CycleEmbryo DetailsResult

Send Your Medical Reports

  
1

Surat:
3rd Floor, Le-Grand Building, N/r Udhana Darwaja, Ring Road.
+91 0261 2633144 | 2633244

Rajkot:
4th Floor, Jasal, Nanawati Chowk ,150 Feet Ring Road.
+91 0281 2580666 | 2585666

Vadodara:
401/402 4th floor, Trivia complex,
Natubhai Circle.

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