Fertility Assessment Questionnaire (Female to be treated)

All parts of this questionnaire are strictly confidential and will be a part of your medical record.

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1. Your consent to Proceed

1. Guy's Assisted Conception Unit are requesting you complete this online questionnaire as we have received a referral regarding treatment for yourself (and / or treatment for your partner if you have one) at our clinic.
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Completing this online form will potentially speed up your ability to access treatment with us. By selecting that you accept to proceed below, you will also be agreeing to allow us to contact you again via email if needed during your journey with us. Some questions are very personal in nature however this portal is encrypted and we of course abide by all data protection laws and confidentiality best practice.
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You are under no obligation to complete the following questionnaire and can select the decline option; however you will still need to complete paper forms that we will either send to you in the post or give to you on your first visit to us if you choose not to complete them online beforehand.
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According to our records you are aware that you have chosen to self fund / pay for private treatment. If that is NOT the case (i.e. you wish to be, or believe you will be funded by the NHS) please contact the Guy's ACU administration team immediately on 0207 188 2300 (initial option 2, followed by the second option 2). *

I accept and consent to complete the following online questionnaire so that Guy's Assisted Conception Unit (ACU) can obtain vital personal and medical information before I attend clinic. I also agree to Guy's ACU contacting me via email from time to time if needed.
I decline to complete the online questionnaire, I do not wish to be communicated with via email and prefer to complete paper hard copies of this questionnaire when I attend clinic.
Select this option if you have completed this questionnaire within the last 6 months (there is no need to complete it again within this time period)

If you DECLINE or if you have completed this questionnaire within the last 6 months please add your FULL name here:

2. Please read the terms and conditions below carefully, and indicate that you have read and agree where indicated:

I have seen the current Pricelist and am aware that I will have an oppurtunity to discuss the treatment fees for this treatment cycle. I agree to pay these within the terms set out by The Assisted Conception Unit at Guy’s & St Thomas’ NHS Foundation Trust.

I understand that this agreement and the pricelist is current at this time, however, the Assisted Conception Unit at Guy’s & St Thomas’ NHS Foundation Trust, may review and revise prices without notice. I agree to pay the tariffs valid at the time of starting our treatment (this is when we start taking our first treatment medication).

I understand and agree to pay all treatment fees, prior to starting the medication and that failure to make payment will result in the treatment cycle being cancelled and a cancellation fee charged. I agree to pay the difference in price, if rates are adjusted by the time we start our medication. I agree that if we fail to attend the appointment or provide less than 48 hours notice, I will be charged £75 and may be removed from the treatment list.

I understand the listed treatment fees do not cover the cost of medication and agree to pay for these separately. I understand that the ACU cannot provide us with the actual costs of the medication as it is supplied by an independent drug company that is not associated with Guy’s & St Thomas’ NHS Foundation Trust.

I understand that our treatment may be cancelled due to clinical reasons or for our own personal reasons and in these cases a Cancellation Fee will be applied, depending upon the stage of treatment at cancellation. I am aware of the different fees applicable and agree to pay these.

I understand that the team at the Assisted Conception Unit will order the appropriate amount of medication for our treatment, however, as dosages may be adjusted during the cycle, I may need to purchase more medication or may have some left over. I agree to pay for the additional medication (delivery charges will be applied). I accept that some high-cost drugs may remain unused and which cannot be returned to the drug company for a refund.

I understand that if a procedure in theatre takes place (either an egg collection or insemination), the full fees for that treatment cycle are applicable (i.e. IVF/ICSI/PGD/FET/IUI etc), irrespective of its outcome.

I understand that our treatment may require additional procedures (such as an SSR, HyCoSy etc.) which are charged separately and are in addition to the procedure costs. I am aware of the costs and accept to pay these on the day of the procedure.

I understand that dependent upon clinical indication, planned treatment may be changed (e.g. IVF to ICSI) as late as on the day of the procedure. I accept that this change will alter the price of treatment (as per the pricelist) and agree to pay the revised price of treatment.

I understand that there is a fee for freezing embryos and agree to pay this when/if I request to have our excess embryos frozen. The fee will cover 12 months storage, after which time, I will need to pay an annual fee to continue the storage, at the prices current at that time.

I understand that our treatment cost covers one follow-up consultation (should the treatment cycle be unsuccessful). The appointment must be within 6 weeks of treatment, after which time a fee for a Follow-Up Consultation will be charged at the rates current at the time.

By selecting 'I Agree' below you are signifying that you have read the above terms and conditions, understand them, and will abide by them should you be accepted for treatment at Guy's Assisted Conception Unit. Failure to select 'I Agree' may result in us being unable to treat you.

Do you agree to accept and abide by Guy's Assisted conception Unit *