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.

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 important operation in the past?*

Do you suffer from a serious illness?*

Do you smoke?*

General information




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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

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