Online Self Referral

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online Self Referral

How to make an appointment

When you submit this form, your information will be reviewed, and an appointment will be made for you. Your appointment details and information will be emailed to you through our online Patient Portal. Should you have any queries or if the appointment date does not suit you, please contact us via the patient portal.

When you visit the Clinic, you’ll be assigned a primary Doctor for consultations and treatment planning. Throughout your treatment cycle, you may interact with various Doctors and clinical staff for specific appointments and tests. After a cycle, a multidisciplinary team, including Doctors, Nurses, and Embryologists, will make recommendations for your next steps. If your Doctor changes, you’ll receive ample notice, and you will be assigned a new Doctor. Throughout your journey with Merrion Fertility Clinic, you will always be cared for by an experienced team, ensuring uninterrupted care.

Self Referral Form

Step 1 of 2

Please indicate the reason for your referral*
Date of Birth*

Day
Month
Year

Enter details for the primary patient undergoing treatment, e.g. Heterosexual couples, please enter female date of birth.
This field is hidden when viewing the form
Female Age input upon Application
Date of Birth*

Day
Month
Year

Enter details for the primary patient looking to freeze their eggs.
This field is hidden when viewing the form
Female Egg Freezing Age input upon Application
Location*
Merrion Fertility Clinic is expanding to Galway with our new satellite service. If you're in the west of Ireland, you now have the option to visit either our main clinic in Dublin or our new location in Galway, this would be for investigations and scans only. We're thrilled to be able to provide you with more convenient options for your fertility journey.

Thank you for your interest in Merrion Fertility Clinic. We're sorry but you do not meet the criteria for an appointment at our clinic.
Understand Why
Thank you for your interest in Merrion Fertility Clinic. We're sorry but you do not meet the criteria for an appointment at our clinic.
Understand Why
If necessary, please provide more detail.
Female Details
Forename*
As stated on passport
Known As
Maiden Name (if applicable)
Surname*
Female Date Of Birth*

DD
MM
YYYY
Address*
Street Address City County Eircode
Home Phone*
Mobile Phone*
Email Address*
Enter Email Confirm Email
PPSN*
First Language*
Nationality*
Occupation*
Do you have health insurance?*
Please note that if you are a VHI member, you may be entitled to benefits for fertility treatment, which are given to you directly by the clinic.
Select your health insurance provider.*
Enter your health insurance provider.*
Policy Number*
Have you previously attended Merrion Fertility Clinic for a doctor consultation?*
GP Name and Address*
How many days is your menstrual cycle? (if applicable)
Date of last menstrual period

Day
Month
Year
Weight in Kilograms (Female)*
BMI assessments will take place at our nurse consultation. Please make sure your weight is entered in Kilograms not Pounds or Stone. You can use this website to convert your weight.
Height in Centimeters (Female)*
Please make sure your height is entered in Centimeters not Millimeters, Feet or Inches. You can use this website to convert your height.
BMI is calculated at (kg/m2) (Female)*
Have you ever had any medical problems / surgery? If yes, please provide details below.*
Summary of your medical problems/surgery details.*
Include childhood problems and medical conditions e.g. asthma infection, gynaecological problems or testicular injuries etc.
Do you have a partner or spouse?*
Partner's Forename*
As stated on passport
Partner's Surname*
Partner's Date Of Birth*

DD
MM
YYYY
This field is hidden when viewing the form
Partners Age input upon Application
Thank you for your interest in Merrion Fertility Clinic. We're sorry but you do not meet the criteria for an appointment at our clinic.
Understand Why
Partner's Contact Number*
Partner's Email*
Partner's First Language*
Partner's Nationality*
Partner's Occupation*
Does your partner have health insurance?*
Please note that if you are a VHI member, you may be entitled to benefits for fertility treatment, which are given to you directly by the clinic.
Select your partner's health insurance provider.*
Partner's health insurance provider*
Partner's Policy Number*
Partner's GP Name and Address
Weight in Kilograms (Partner)*
Please make sure your weight is entered in Kilograms not Pounds or Stone. You can use this website to convert your weight.
Height in Centimeters (Partner)*
Please make sure your height is entered in Centimeters not Millimeters, Feet or Inches. You can use this website to convert your height.
BMI is calculated at (kg/m2) (Partner)*
Are you trying to conceive?*
When did you start trying to conceive?*
Have you ever had fertility treatment elsewhere? If yes, please provide Merrion Fertility Clinic with a summary of your care below.*
Summary of your care and/or previous pregnancy details
Next of Kin*
Relation to Patient*
Next of Kin Contact Details*
Please upload any previous test results
Drop files here or

Max. file size: 20 MB, Max. files: 5.
Do you require special needs assistance?*
If yes, please provide more detail.
Do you require an Interpreter?*
If yes, please provide more detail.
How did you hear about Merrion Fertility Clinic?*
Would you prefer an In-Person or Online Initial Consultation at Merrion Fertility Clinic?*
Please note for all consultations, where applicable both partner's must be in attendance for the consultation e.g. In-Person Consultation - both partner's attend the clinic.
Other website*
Other*
Confirmation*
I confirm that I have read and understand the statement below.
When you submit this form, your information will be reviewed and an appointment will be made for you. Your appointment details and information can be accessed by logging in to our online patient portal (you will receive a link to register). Should you have any queries or if the appointment date does not suit, please contact us.
Consent*
I agree to the Privacy Policy.

Printable Forms

Referrals can be sent by Post to:
Merrion Fertility Clinic,
60 Lower Mount St,
Dublin 2

Referrals can be sent by email to:
info@merrionfertility.ie

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