Gamete Intrafallopian Transfer (GIFT) Patient Intake Questionnaire
Complete this intake questionnaire so the fertility clinic can review your history, current medications, allergies, and readiness for GIFT evaluation.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Fertility Treatment History
Have you had any prior fertility evaluations or treatments?
*
No prior evaluation or treatment
Yes, evaluation only
Yes, treatment only
Yes, both evaluation and treatment
Other
Briefly describe any previous fertility procedures or treatments
How long have you been trying to conceive?
*
Please Select
Less than 6 months
6-12 months
1-2 years
More than 2 years
Not currently trying
Other
Current Health and Procedure Readiness
Current medications or supplements
Known allergies
Acknowledgment
*
I understand this is an intake questionnaire for evaluation and the clinic may contact me to discuss next steps.
Submit
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