Patient Onboarding Form

1
Name
First Name
Last Name
2
Email* This field is required.
example@example.com
3
What brings you here?* This field is required.
Please Select
Please Select
Starting Fertility Care
Repeat Fertility Treatments
Options to delay parenthood (For ex. Egg/Sperm freezing)
Other
4
Tell us about your situation* This field is required.
Please Select
Please Select
Freeze eggs
Freeze sperm
Freeze embryos
5
Do you have any medical conditions that led you to this decision?* This field is required.
YESNO
6
Please provide more details* This field is required.
7
What treatments have you had?* This field is required.
Please Select
Please Select
IVF
IVF with ICSI
IVF with donor eggs
IUI
Other
8
Have you previously had a fertility diagnoses?* This field is required.
YESNO
9
Please identify the statement that matches your circumstance* This field is required.Please select ALL that apply
I have previously had care with the NHS
I have paid for care privately
I have used insurance to pay for care
I have had 1 round of treatment
I have had 2 rounds of treatment
I have had 3 rounds of treatment
I have had 4 or more rounds of treatment
10
Do you have any specific needs, you're aware of that we should considered?* This field is required.
Please Select
Please Select
Donor - Sperm
Donor - Egg
Donor - Embryo
Surrogacy
Genetic Testing
Other
N/A
11
For how long have you been trying to conceive?* This field is required.(With or without treatment)
Please Select
Please Select
Less than 1 year
Past 2-3 years
3-4 years
More than 4 years
12
Have you had any of the following before?* This field is required.
Please Select
Please Select
Natural Pregnancies
Lost Pregnancies
Abortions
Not Applicable
13
What is your age?* This field is required.
14
What is your gender assigned at birth?* This field is required.
Please Select
Please Select
Male
Female
15
What is your relationship status?
Please Select
Please Select
Single
Heterosexual Couple
LGBTQ+ Couple
16
Is anyone else joining your care?
YESNO
17
Please state the age of your partner
18
What is your partners assigned gender at birth?
Please Select
Please Select
Male
Female
19
Where would you like to receive your treatment?* This field is required.
Please Select
Please Select
Spain
Italy
Greece
Czech Republic
Anywhere
Other
20
If, 'Other' - Please state your region of preference
21
Please state the type of clinic you would prefer* This field is required.
Boutique
Large Chain
Hospitals
22
How soon would you like to start?* This field is required.
Please Select
Please Select
Immediately
Next 3 months
3 - 6 months
6 - 12 months
Just browsing options
23
When did you finish your treatment cycle, if applicable?
Date
Year
Month
Day
24
Do you or your partner have any special needs?(This includes any medical conditions/past history of cancer care)
25
Lastly, what country are you a resident in?* This field is required.
26
Is there any particular reason you are not getting care in your country?* This field is required.
27
If you would like to include your partner in any communication henceforth, please share their name and email.This is not for any marketing purposes and this information will remain confidential.*
Name
Please enter your email
28
Please confirm your consent to the following* This field is required.
I consent, with my partner (if applicable) to share my data with recommended clinics to proceed to a first consult
I consent, with my partner (if applicable) to share my details with Antares Health
All the information share, is true to the best of my knowledge
I consent, with my partner (if applicable) to give Antares Health detailed feedback along my journey as a new platform user, in exchange for benefits provided by the Antares Team
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