Personal information for social freezing

In order to prepare for your visit, we would appreciate it if you could provide some answers to the following questions. Alternatively, you can download a PDF here to print and fill in with your personal information.

The form will be treated confidentially and only used for the purposes of your treatment.
None of the data provided will be transferred to third parties!

Our questions for her

All questions marked with * are required fields.



Period / monthly cycle*

Former pregnancies?*

Do you have any allergies?*

Do you take medication?*

Have you had an operation in the past?*

Do you suffer from a serious illness?*

Do you smoke?*

General information




How did you hear about us?

Do you already have an appointment with us?*

Data protection notice

We would like to alert you to the fact that all data transmitted to us is stored and processed with the help of electronic data processing. The data entered in this form will be deleted after submission. We handle the information you provide with strict confidentiality and do not transfer it to any other party. Please consult our data protection notice.


SSL

All forms within our website use a secured connection through SSL encryption (Secure Socket Layer protocol). Your data is also sent to us via secure connection. Your data is protected during transmission by the SSL protocol and 256-bit key and cannot be viewed by third parties. The connection secured with SSL encryption can be recognized by the extension https:// in the address bar.