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Enhancing Fertity with Oriental Medicine

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RIVERSIDE ACUPUNCTURE & WELLNESS CENTRE
Enhancing Fertility With Oriental Medicine
(613) 526-3168 Admin@AcupunctureOttawa.com
Name:
Date:
Address:
Home Phone
Business Phone
Phone Cell
Date of Birth:
Occupation:
Medical Doctor:
Referred By:
Insurance:
Smoker:
Height:
Weight:
Pregnant:
Breast Implants
Blood type:
Right Handed
Left Handed
Any Blood borne Infections (Hepatitis, HIV, etc.)
REASON FOR CONSULTATION:
How long has this been a concern:
Diagnosis by an MD:
If you are currently undergoing A.R.T., when (approximately)is your next egg retrieval date?

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