Please complete the Patient Demographic Form at least three days prior to your appointment. We look forward to your upcoming appointment.

You can also download a PDF of this form by clicking HERE and email a copy to info@laivfclinic.com or print and fax a copy to 310-691-1116.

Patient Demographic Form

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• Email
  这个字段是用于验证目的，应该保持不变。
• Patient Name
  第一页 后一页
• Sex of Patient
  • Female
  • Male
• Date of Birth of Patient
• Partner Name
  第一页 后一页
• Sex of Partner
  • Female
  • Male
• Date of Birth - Partner
• Address
  街道地址 地址2 (街道) 市 州/省/地区 邮编/邮政编码 * 澳门阿尔巴尼亚阿尔及利亚阿富汗阿根廷阿联酋阿曼阿塞拜疆埃及埃塞俄比亚爱尔兰爱沙尼亚安道尔安哥拉安圭拉岛安提瓜岛和巴布达奥地利奥兰群岛澳洲巴巴多斯巴布亚新几内亚巴哈马巴基斯坦巴拉圭巴勒斯坦国巴林巴拿马巴西白俄罗斯百慕大保加利亚北马里亚纳群岛北马其顿贝宁比利时冰岛波多黎各波兰波斯尼亚和黑塞哥维那玻利维亚伯利兹博茨瓦纳不丹布吉纳法索布隆迪布维岛赤道几内亚丹麦东帝汶多哥多米尼加共和国多米尼克厄瓜多尔厄立特里亚法国法罗群岛法属波利尼西亚法属南部领土菲律宾斐济芬兰佛得角冈比亚 (西非的独立国)刚果刚果民主共和国的哥伦比亚哥斯达黎加格林纳达格陵兰根西岛古巴关岛圭亚那哈萨克斯坦海地荷兰赫德岛和麦克唐纳岛黑山共和国洪都拉斯基里巴斯吉布提吉尔吉斯斯坦几内亚几内亚比绍加拿大加纳加蓬柬埔寨津巴布韦喀麦隆卡塔尔开曼群岛科摩罗科特迪瓦科威特克罗地亚肯尼亚库拉索拉脱维亚莱索托黎巴嫩立陶宛利比里亚利比亚列支敦士登卢森堡卢旺达罗马尼亚马达加斯加马恩岛马尔代夫马耳他马拉维马来西亚马里马绍尔群岛毛里求斯毛里塔尼亚美国美属萨摩亚孟加拉国秘鲁密克罗尼西亚摩尔多瓦摩洛哥摩纳哥莫桑比克墨西哥纳米比亚南非南极洲瑙鲁尼加拉瓜尼泊尔尼日尔尼日利亚挪威帕劳群岛葡萄牙乔治亚州日本瑞典瑞士萨尔瓦多萨摩亚群岛塞尔维亚塞拉利昂塞内加尔塞浦路斯塞舌尔群岛沙特阿拉伯圣多美和普林西比圣基茨和尼维斯圣卢西亚岛圣马丁岛圣马力诺圣文森特和格林纳丁斯斯里兰卡斯洛伐克斯洛文尼亚斯瓦尔巴岛和扬马延岛苏丹苏里南河所罗门群岛索马里塔吉克斯坦台湾(中国)泰国汤加特立尼达和多巴哥突尼斯图瓦卢土库曼斯坦瓦努阿图危地马拉维尔京群岛,美国维尔京群岛,英国委内瑞拉乌干达乌克兰乌拉圭乌兹别克斯坦西班牙希腊香港证券交易所新加坡新西兰匈牙利牙买加亚美尼亚也门伊拉克伊朗以色列意大利印度印度尼西亚英国约旦赞比亚泽西岛乍得智利中非共和国中国ArubaBonaire, Sint Eustatius and SabaBritish Indian Ocean TerritoryBrunei DarussalamChristmas IslandCocos IslandsCook IslandsCzechiaDeutschland (德国)EswatiniFalkland IslandsFrench GuianaGibraltarGuadeloupeHoly SeeKorea, Democratic People's Republic ofKorea, Republic ofLao People's Democratic RepublicMartiniqueMayotteMontserratNew CaledoniaNiueNorfolk IslandPitcairnRéunionRussian FederationSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint MartinSaint Pierre and MiquelonSouth Georgia and the South Sandwich IslandsSouth SudanSyria Arab RepublicTanzania, the United Republic ofTokelauTürkiyeTurks and Caicos IslandsUS Minor Outlying IslandsViet NamWallis and FutunaWestern SaharaМонгол улс (蒙古)မြန်မာ (缅甸) 国家
• Home Phone
• Work Phone
• Email
• Patient Occupation
• Patient Employed by:
• Partner Occupation
• Partner Employed by:
• Purpose of Visit
  examples; semen analysis, initial consultation
• Patient's Social Security Number
• Partner's Social Security Number
• Do you have medical insurance?
  • Yes
  • No
• Your Preferred Pharmacy
• Your Pharmacy's Phone
• Your Pharmacy's Zip Code
  邮编/邮政编码
• May we leave messages, such as lab results appointments or other medical information on an answering machine or with another person who answers the phone at that number or in case of an emergency?
  • Yes
  • No
• How did you hear about us?
  Physician ReferralSeminarGoogle SearchFacebook/ InstagramWord of mouthPrevious patient of LA IVFInsuranceOther
• Referring Physician Name
• Referring Physician Phone
• Referring Physician Fax Number
• Referring Physician Address
  街道地址 市 州/省/地区 邮编/邮政编码 * 澳门阿尔巴尼亚阿尔及利亚阿富汗阿根廷阿联酋阿曼阿塞拜疆埃及埃塞俄比亚爱尔兰爱沙尼亚安道尔安哥拉安圭拉岛安提瓜岛和巴布达奥地利奥兰群岛澳洲巴巴多斯巴布亚新几内亚巴哈马巴基斯坦巴拉圭巴勒斯坦国巴林巴拿马巴西白俄罗斯百慕大保加利亚北马里亚纳群岛北马其顿贝宁比利时冰岛波多黎各波兰波斯尼亚和黑塞哥维那玻利维亚伯利兹博茨瓦纳不丹布吉纳法索布隆迪布维岛赤道几内亚丹麦东帝汶多哥多米尼加共和国多米尼克厄瓜多尔厄立特里亚法国法罗群岛法属波利尼西亚法属南部领土菲律宾斐济芬兰佛得角冈比亚 (西非的独立国)刚果刚果民主共和国的哥伦比亚哥斯达黎加格林纳达格陵兰根西岛古巴关岛圭亚那哈萨克斯坦海地荷兰赫德岛和麦克唐纳岛黑山共和国洪都拉斯基里巴斯吉布提吉尔吉斯斯坦几内亚几内亚比绍加拿大加纳加蓬柬埔寨津巴布韦喀麦隆卡塔尔开曼群岛科摩罗科特迪瓦科威特克罗地亚肯尼亚库拉索拉脱维亚莱索托黎巴嫩立陶宛利比里亚利比亚列支敦士登卢森堡卢旺达罗马尼亚马达加斯加马恩岛马尔代夫马耳他马拉维马来西亚马里马绍尔群岛毛里求斯毛里塔尼亚美国美属萨摩亚孟加拉国秘鲁密克罗尼西亚摩尔多瓦摩洛哥摩纳哥莫桑比克墨西哥纳米比亚南非南极洲瑙鲁尼加拉瓜尼泊尔尼日尔尼日利亚挪威帕劳群岛葡萄牙乔治亚州日本瑞典瑞士萨尔瓦多萨摩亚群岛塞尔维亚塞拉利昂塞内加尔塞浦路斯塞舌尔群岛沙特阿拉伯圣多美和普林西比圣基茨和尼维斯圣卢西亚岛圣马丁岛圣马力诺圣文森特和格林纳丁斯斯里兰卡斯洛伐克斯洛文尼亚斯瓦尔巴岛和扬马延岛苏丹苏里南河所罗门群岛索马里塔吉克斯坦台湾(中国)泰国汤加特立尼达和多巴哥突尼斯图瓦卢土库曼斯坦瓦努阿图危地马拉维尔京群岛,美国维尔京群岛,英国委内瑞拉乌干达乌克兰乌拉圭乌兹别克斯坦西班牙希腊香港证券交易所新加坡新西兰匈牙利牙买加亚美尼亚也门伊拉克伊朗以色列意大利印度印度尼西亚英国约旦赞比亚泽西岛乍得智利中非共和国中国ArubaBonaire, Sint Eustatius and SabaBritish Indian Ocean TerritoryBrunei DarussalamChristmas IslandCocos IslandsCook IslandsCzechiaDeutschland (德国)EswatiniFalkland IslandsFrench GuianaGibraltarGuadeloupeHoly SeeKorea, Democratic People's Republic ofKorea, Republic ofLao People's Democratic RepublicMartiniqueMayotteMontserratNew CaledoniaNiueNorfolk IslandPitcairnRéunionRussian FederationSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint MartinSaint Pierre and MiquelonSouth Georgia and the South Sandwich IslandsSouth SudanSyria Arab RepublicTanzania, the United Republic ofTokelauTürkiyeTurks and Caicos IslandsUS Minor Outlying IslandsViet NamWallis and FutunaWestern SaharaМонгол улс (蒙古)မြန်မာ (缅甸) 国家
• Emergency Contact
  第一页 后一页
• Emergency Contact Phone
• PLEASE ENTER YOUR INITIALS TO SIGN THE QUESTIONNAIRE*
  The undersigned declares that the above information is true and accurate:
• Consent*
  I confirm that all the information I have entered is correct and I have read, understand that LAIVF CLINIC will contact me using the information provided.
• Privacy*
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• Please enter your email to receive a copy of this Patient Demographic Form
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• I consent to receive text messages, phone calls & emails with the information I have provided above. I also recognize that I can stop that communication at any time & La IVF Clinic will honor my request.
  • I consent to receive text messages, phone calls & emails with the information I have provided above. I also recognize that I can stop that communication at any time & La IVF Clinic will honor my request.