Toronto Infertility Clinic: Egg Donation Toronto (Assisted Reproduction)

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56 Aberfoyle Crescent,
Suite 300

Toronto, Ontario, M8X 2W4

416-233-8111 (tel)

1-877-317-6079 (toll free)

info@repromed.ca

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	For More Information:
	> in vitro fertilization
	> egg donation
	> female infertility
	> sperm bank
	> microsurgical tubal reconstruction

Patient Information and Forms

It would be our pleasure to set-up an appointment and review your case. Before the consultation (on site or via the phone) we require some information. Below are the Patient History form and Consent to Disclose Personal Health Information. Please complete both forms and email or fax them back at your earliest convenience. Our fax number is 416-233-8360. Once we receive the forms we can put together a chart and a team member will contact you to arrange a time for an appointment. Be sure to fill out the Patient Information Request below so have all your correct information to contact you.

For all onsite appointments we require you to bring your Health Card and suggest that you bring your partner (if applicable).

Patient Forms for Initial Consultation (in pdf)
1.	Patient History Form
2.	Consent to Disclose Personal Health Information

Patient Forms Required for Subsequent Visit (in pdf)
1.	Consent for Testing
2.	Email Consent Form

Please fill out all the fields so we can serve you best.

First Name:
Last Name:
Email:
Home Phone:
Business Phone:
Cell Phone:
Preferred Number to Reach You: home phone Business Cell
Address:
City
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Ontario Health Card #
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