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UPITINIK ZA PACIJENTE za Surogat programe

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.

PATIENT FORM for Surrogacy programs

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