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UPITNIK ZA PACIJENTE za programe donacije jajnih ćelija

Molim vas da popunite sva navedena polja u Upitniku. Sve lične podatke dajete klinici i Upitnik se kao takav smatra poverljivim dokumentom i zaštićen je protiv zloupotrebe zakonom. Mi ćemo koristiti vaše podatke samo za sopstvene potrebe i nećemo ih davati u bilo kojoj formi drugim osobama.

Informacije u ovom upitniku su nam od izuzetne važnosti i pomoći će lekarima da naprave najbolju moguću opciju lečenja za vas.

Upitnik možete popuniti i na mobilnom telefonu.

PATIENT FORM for Egg donation

Please complete this Form by filling all the required data. All the personal data you disclose to Clinic in this Form it is cosidered confidentioal and is protected against misuse under the law. We will only use your personal data for our needs and will not provide them in any form to another person.

The information in the Form is of high importance for us and it will help the physician in designing the best treatment option for you.

You can fill in document on your mobile phone as well.


Molim vas napišite nam podatke o vašim ranijim IVF pokušajima / Please tell us about your previous IVF treatment attempts.










Molim vas navedite uzroke neplodnosti ako su vam poznati / Please indicate your infertility causes (if known)

Godine majke / Advanced maternal age
Muški faktor / Male factor
Nepravilnosti rada imunog sistema / Immune system disorders
Oštećenje jajovoda / Damage to fallopian tubes
Problemi sa hormonima / Hormonal causes
Endometrioza / Endometriosis
Posledice ranijih operacija / Consequences of previous surgeries
Urinarne infekcije ili infekcije reproduktivnih organa / Infections within urinary and reproductive organs
Anatomske abnormalnosti / Anatomical abnormalities
Neodgovarajuća težina / Improper body mass
Bolesti metabolizma / Metabolic diseases

Da li imate u vašoj porodici neke nasledne poremećaje ili probleme sa fertilitetom? / Are there any hereditary disorders or fertility issues in your family?

Hematološke ili neurološke bolesti / Hematological or neurological diseases (Huntington`s chorea)
Psorijaza / Psoriasis
Dijabetes / Diabetes
Rak / Cancer
Problemi sa štitastom žlezdom / Thyroid failure
Ankoreksija / Anorexia
Albinizam / Albinism
Daunov sindrom / Down syndrome
Celijaklija / Celiac disease
Galaktosemija / Galactosemia
Anemija / Anemia
Zečija usna / Cleft lip
Hemofilija / Hemophilia


INFORMACIJE O PARTNERU / PARTNER INFORMATION.

Molim vas napišite za koje ste programe sa doniranim jajnim ćelijama ili spermom zainteresovani? / Please tell us about which programs with donated oocytes or sperm you are interested in?

Promotivni program donacije jajnih ćelija / Budget egg donation program
Donacija jajnih ćelija iz svežeg ciklusa / Egg donation with fresh donor oocytes
Kombinovani IVF program sa sopstvenim i doniranim jajnim ćelijama / Combined IVF with own and donor oocytes
Garantovani program donacije jajnih ćelija / Guaranteed Egg donation Money Back System
Program donacije jajnih ćelija sa donacijom sperme / Egg donation with sperm donation program
Usvajanje embriona / Embryo adoption