Online Self Referral

Forename (*)

Surname (*)

Date of Birth (*)

Address(*)

Contact Number (*)

Email address (*)

Reason for referral (*)

When did you start trying to conceive? (*)

How many days is your menstrual cycle (I.e. 28 days)? (*)

Date of last menstrual period

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

How did you hear about Merrion Fertility Clinic?(*)

If other has been selected above, please specify here

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How to Make a Doctor Appointment With Us

Once you have been referred to MFC, or have completed the online self referral form, your information will be reviewed by our Clinical Director, Prof. Mary Wingfield, and an appointment will be made for you. You will be sent an appointment pack via post containing information regarding your appointment. Should you have any queries or if the appointment date does not suit please contact our administration team on 016635000.

For information on booking a semen analysis appointment please click here.

Printable Forms

Referrals can be sent by:

Post to:
Merrion Fertility Clinic,
60 Lower Mount St,
Dublin 2
E-mail:
info@merrionfertility.ie

Fertility Registration Forms

Patient Registration Form Download↓

Male Questionnaire Form Download↓

Female Questionnaire Form Download↓

Gynaecology Registration Forms

Gynaecology Registration Form Download↓

Gynaecology Questionnaire Form Download↓

Contact Form

How to Make a Doctor Appointment With Us

Printable Forms

Fertility Registration Forms