IVF Miracle Baby
Giving Hope.... Creating Life
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Please complete the form below with as much information as possible and Dr Wiwat will respond to your enquiry within 24-hours.
All information will remain strictly confidential and will not be passed to any other person or organization.
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denotes mandatory fields
PERSONAL INFORMATION
Name of Female Partner
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Name of Male Partner
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Email Address
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Country of Residence
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---Select the Country ---
Afghanistan +93
Albania +355
Alderney +999999
Algeria +213
American Samoa +684
Andorra +376
Angola +244
Anguilla +264
Antarctica +672
Antigua and Barbuda +268
Argentina +54
Armenia +374
Aruba +297
Australia +61
Austria +43
Azerbaijan +994
Azores +351
Bahamas +242
Bahrain +973
Bangladesh +880
Barbados +246
Belarus +375
Belgium +32
Belize +501
Benin +229
Bermuda +441
Bhutan +975
Bolivia +591
Bosnia and Herzegovina +387
Botswana +267
Bouvet Island +999999
Brazil +55
British Indian Ocean Territory +999999
Brunei Darussalam +673
Bulgaria +359
Burkina Faso +226
Burundi +257
Cambodia +855
Cameroon +237
Canada +1
Canary Islands +34
Cape Verde +238
Cayman Islands +345
Central African Republic +236
Chad +235
Chile +56
China +86
Christmas Island +672
Cocos (Keeling) Islands +61
Colombia +57
Comoros +269
Congo +242
Congo (Republic) +243
Cook Islands +682
Costa Rica +506
Cote D'Ivoire +225
Croatia +385
Cuba +53
Cyprus +357
Czech Republic +420
DO NOT USE +999999
Denmark +45
Djibouti +253
Dominica +767
Dominican Republic +809
East Timor +670
Ecuador +593
Egypt +20
El Salvador +503
Equatorial Guinea +240
Eritrea +291
Estonia +372
Ethiopia +251
Falkland Islands (Malvinas) +500
Faroe Islands +298
Fiji +679
Finland +358
France +33
French Guiana +594
French Polynesia +689
French Southern Territories +689
Gabon +241
Gambia +220
Georgia +995
Germany +49
Ghana +233
Gibraltar +350
Global +44
Greece +30
Greenland +299
Grenada +473
Guadeloupe +590
Guam +671
Guatemala +502
Guernsey +44
Guinea +224
Guinea-Bissau +245
Guyana +592
Haiti +509
Heard and McDonald Islands +999999
Herm +999999
Holy See (Vatican City State) +379
Honduras +504
Hong Kong +852
Hungary +36
Iceland +354
India +91
Indonesia +62
Iran (Islamic Republic) +98
Iraq +964
Ireland +353
Isle of Man +44
Israel +972
Italy +390
Jamaica +876
Japan +81
Jersey +44
Jordan +962
Kazakhstan +7
Kenya +254
Kiribati +686
Korea (Republic) +82
Korea, Democratic People's Rep +850
Kuwait +965
Kyrgyzstan +996
Laos People's Democratic Rep +856
Latvia +371
Lebanon +961
Lesotho +266
Liberia +231
Libyan Arab Jamahiriya +218
Liechtenstein +41
Lithuania +370
Luxembourg +352
Macau +853
Madagascar +261
Madeira +351
Malawi +265
Malaysia +60
Maldives +960
Mali +223
Malta +356
Marshall Islands +692
Martinique +258
Mauritania +222
Mauritius +230
Mayotte +269
Mexico +52
Micronesia (Federated States of) +691
Moldova +373
Monaco +377
Mongolia +976
Montserrat +664
Morocco +212
Mozambique +258
Myanmar +95
Namibia +264
Nauru +674
Nepal +977
Netherlands +31
Netherlands Antilles +599
New Caledonia +687
New Zealand +64
Nicaragua +505
Niger +227
Nigeria +234
Niue +683
Norfolk Island +672
Northern Mariana Islands +670
Norway +47
Oil Industry +999999
Oman +968
Pakistan +92
Palau +680
Panama +507
Papua New Guinea +675
Paraguay +595
Peru +51
Philippines +63
Pitcairn +155
Poland +48
Portugal +351
Puerto Rico +787
Qatar +974
Rep of Macedonia +389
Reunion +262
Romania +40
Russian Federation +7
Rwanda +250
Saint Helena +290
Saint Kitts and Nevis +869
Saint Lucia +758
Saint Pierre and Miquelon +508
Samoa +685
San Marino +378
Sao Tome and Principe +239
Sark +999999
Saudi Arabia +966
Senegal +221
Seychelles +248
Sierra Leone +232
Singapore +65
Slovakia +421
Slovenia +386
Solomon Islands +677
Somalia +252
South Africa +27
Spain +34
Sri Lanka +94
St Vincent and the Grenadines +784
Sth Georgia & Sth Sandwich Is +999999
Sudan +249
Suriname +597
Svalbard and Jan Mayen +999999
Swaziland +268
Sweden +46
Switzerland +41
Syrian Arab Republic +963
Taiwan +886
Tajikistan +992
Tanzania (United Republic) +255
Thailand +66
Togo +228
Tokelau +690
Tonga +676
Travelling +999999
Travelling(Middle East) +999999
Trinidad and Tobago +868
Tunisia +216
Turkey +90
Turkmenistan +993
Turks and Caicos Islands +649
Tuvalu +688
UAE +971
US Minor Outlying Islands +1
USA +1
Uganda +256
Ukraine +380
United Kingdom +44
Uruguay +598
Uzbekistan +998
Vanuatu +678
Venezuela +58
Vietnam +84
Virgin Islands (British) +284
Virgin Islands (U.S.) +340
Wallis and Futuna Islands +681
Western Sahara +999999
Yemen +967
Yugoslavia +391
Zambia +260
Zimbabwe +263
Telephone Number
Intended Treatment
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How long have you been trying to get pregnant?
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Reason given for infertility
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MEDICAL HISTORY OF FEMALE PARTNER
Age
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Height
Cms
Weight
Pounds
Kilo
Details of menstrual cycle
*
Details of any fertility tests
Number of miscarriages/abortions
*
Number of previous live births
Details of any previous ART
Current medication
*
MEDICAL HISTORY OF MALE PARTNER
Age
*
18
19
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Height
Cms
Weight
Pounds
Kilo
Previous pregnancies with partner(s)
*
Have you had a semen analysis report?
*
If yes, date of report
Sperm count
Motility
Morphology
Current medication
*
Questions or Comments on
IVF Miracle Baby?
CALL
: +66-879-754-040 | Japanese : (66)856-631-110 | Fax: +66-2509-478,
E-mail
: info@ivfmiraclebaby.com
