City Fertility Centre - Electronic Registration

Andrology Registration Form
 
Thank you for booking in for an andrology (sperm test) appointment with City Fertility.

Prior to your andrology appointment you are required to complete the registration form below. This information will help us to prepare in advance for your appointment. If you have a partner, please also complete their details in the registration form below.


About the Testing


Facilities are available at the clinic to produce your semen sample. You may produce your sample at home if you prefer, provided the sample is received at our laboratory within one hour of production (an appointment is still required). It is preferable that you have not ejaculated for at least two full days and not more than five days prior to producing your semen sample.

Please note: that when producing your sample you must not use any lubricants as these may affect the quality of the sample. The sample must also not come into contact with any water.

On the day of your appointment you will need to bring your referral as well as photo ID in the form of either a driver's licence, passport or student ID card for identification purposes. Please note if you have been referred to the clinic for a sperm freeze you are required to have completed pathology screening bloods (HIV, Hep B, Hep C) prior to your appointment, please organise these through your referring Doctor.

Please note that payment for all testing is required on the day of your appointment. Please feel free to contact our friendly patient services team for information regarding the costs associated with andrology testing.


Confidentiality


We understand the importance of protecting your personal information and have security measures in place to ensure the information submitted is treated as private and confidential as per our Privacy Collection Statement and Privacy Policy and the Terms and Conditions of this website.

If you need more information please contact our friendly staff to discuss any questions you may have.

We are here to help.


Please select the clinic that you are attending: *    

Chill Egg Freeze - Global CHA IVF Partners Please indicate here if you are undergoing elective
egg freezing under our Chill program
     

Name of person having Andrology test

Last Name: (family name) *
First Name: *
Middle Name:
Maiden Name/Former Last Name:
Why do we ask questions regarding sex, sexuality and gender?

Working within the health care sector and providing fertility treatments, we aim to provide a truly inclusive service for all our patients.

To do so there are times we need to ask questions which relate to a patient’s sex, sexuality and gender in order to be able to recommend and provide the most suitable treatment options to assist you.

As a leader in LGBTI+ fertility services, we are committed to providing a high quality and inclusive service to you.
What sex were you assigned at birth? (i.e. what sex was assumed/placed on your original birth certificate) *  
Were you born with a variation of sex characteristics? (this is sometimes called intersex variation)  
Which of the following best describe your current gender identity? *
Do you consider yourself to be:
Pro-nouns:
Date of Birth: *
  /     /  
Residential Address: *  
Town / Suburb: *
   State: *
   Postcode: *
Postal Address: *   ↓ Same as Residential    
Town / Suburb: *
   State: *
   Postcode: *

Home Telephone: *   Work Telephone:
or
Mobile Telephone: *    
Preferred Method of Contact: *  
Email Address: *
Confirm the Email Address: *
Occupation:
Please indicate the suburb and postcode of where your main place of work/employment is located (If applicable):   
Town / Suburb:
   Postcode:
  
At City Fertility we communicate with patients in a variety of ways.

At City Fertility we communicate with patients in a variety of ways.

We use the contact information that you provide to assist us to deliver our services.

We aim to be as discrete as possible when we communicate with you in order to protect your privacy.

Please note that the information we send may include sensitive personal details relating to your health/treatment.

By providing us with your details it is implied that you consent to us contacting you via phone, text message, email and or post.

Please let staff know if you wish not to be contacted via a certain medium.

Please refer to our privacy policy for more information.
Are you an Australian or New Zealand Citizen? *  
Are you of Aboriginal or Torres Strait Islander Origin? *
 
 
Country of Birth: * Country of Residence: *
Ethnic Background: *
First Language: *
Do you require an interpreter? *  
If Yes, for which language?
Do you have an Australian Medicare card number? *  
Medicare Number: *
First name as on Medicare card: * Last name as on Medicare card: *
Medicare Card Reference Number: *    
Medicare Card Expiry Date: *
  /  
Do you have a Health Care Card? *  
Health Care Card Number: *
Health Care Card Expiry Date: *
  /  
Name of Private Health Fund:
Private Health Membership Number:
Private Health Level of Cover:
Known Allergies: - e.g. pollen, tree nuts, silicates, penicillin, etc. *
Height: cm / centimetres *   Weight: kg / kilograms *   BMI:
Emergency Contact Name: *   Emergency Contact Number: *

Referring GP and Couple Requirements


Referring Family Doctor (GP):
Name: *
Address: *
you do not have a City Fertility Specialist please select the option “Temp professional”
City Fertility Specialist: *
Do either you or your partner (if applicable) have a disability? *  
If Yes, please let us know about any adjustments you may require:
How did you hear about the clinic? *

Patient's Previous Treatments

Have you previously undergone Intrauterine (IUI) Insemination cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously undergone IVF cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously frozen embryos? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
If you have had treatment at another IVF clinic please provide the main reason for changing clinics:  

Partner's Details (if applicable)

Do you have a partner? *  
Please complete the following questions relating to your partner.
Last Name: (family name) *
First Name: *
Middle Name:
Maiden Name/Former Last Name:
What sex were you assigned at birth? (i.e. what sex was assumed/placed on your original birth certificate) *  
Were you born with a variation of sex characteristics? (this is sometimes called intersex variation)  
Which of the following best describe your current gender identity? *
Do you consider yourself to be:
Pro-nouns:
Date of Birth: *
  /     /  
Residential Address: *  ↓ Same as Patient
Town / Suburb: *
   State: *
   Postcode: *
Postal Address: *  ↓ Same as Patient    ↓ Same as Residential
Town / Suburb: *
   State: *
   Postcode: *
↓ Same contact & email details as the Patient
Home Telephone: *   Work Telephone:
or
Mobile Telephone: *    
Preferred Method of Contact: *  
Email Address: *
Confirm the Email Address: *
Occupation:
Please indicate the suburb and postcode of where your main place of work/employment is located (If applicable):   
Town / Suburb:
   Postcode:
  
Are you an Australian or New Zealand Citizen? *  
Are you of Aboriginal or Torres Strait Islander Origin? *
 
 
Country of Birth: * Country of Residence: *
Ethnic Background: *
First Language: *
Do you require an interpreter? *  
If Yes, for which language?
Do you have an Australian Medicare card number? *  
Medicare Number: *
First name as on Medicare card: * Last name as on Medicare card: *
Medicare Card Reference Number: *    
Medicare Card Expiry Date: *
  /  
Do you have a Health Care Card? *  
Health Care Card Number: *
Health Care Card Expiry Date: *
  /  
Name of Private Health Fund:
Private Health Membership Number:
Private Health Level of Cover:
Known Allergies: - e.g. pollen, tree nuts, silicates, penicillin, etc. *
Height: cm / centimetres *   Weight: kg / kilograms *   BMI:
Emergency Contact Name: *   Emergency Contact Number: *

Partner's Previous Treatments

Have you previously undergone Intrauterine (IUI) Insemination cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously undergone IVF cycles? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
Have you previously frozen embryos? *  
If Yes, please provide details below
Number of cycles:
When:
Where:
If you have had treatment at another IVF clinic please provide the main reason for changing clinics:  
Do you consent to our Marketing team contacting you in relation to marketing and media activities? *  

If you no longer wish to receive information from us at any stage, please contact the clinic. Please refer to our privacy policy for more information.

The " * " symbol indicates where form-values are required / mandatory.