LINK4MED

LINK4MED

PATIENT FORM for Surrogacy programs

LINK4MED

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.

    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 surogat programe zainteresovani? / Please tell us about which Surrogacy programs you are interested in?

    Surogat program sa sopstvenim jajnim ćelijama i sopstvenom spermom/Surrogacy program with own oocytes and sperm
    Surogat program sa sopstvenim jajnim ćelijama i doniranom spermom/Surrogacy program with own oocytes and donor sperm
    Surogat program sa doniranim jajnim ćelijama i sopstvenom spermom/Surrogacy program with donor oocytes and own sperm
    Surogat program sa doniranim embrionom/Surrogacy program with donor embryo
    Surogat program sa FET - zamrznutim sopstvenim embrionom/Surrogacy program with FET - frozen embryo
    Garantovani surogat program / Guaranteed Surrogacy program

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