Book Consultation • Merrion Fertility Clinic

How to make an appointment

Online Referral

"*" indicates required fields

Please indicate the reason for your referral*

If "Other"*

Date of Birth*

Enter details for the primary patient undergoing treatment, e.g. Heterosexual couples, please enter female date of birth.

Female Age input upon Application

Date of Birth*

Enter details for the primary patient looking to freeze their eggs.

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*

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*

GP 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?*

Do you and your partner both wish to undertake fertility investigations/testing?*

Partner's Forename*

As stated on passport

Partner's Surname*

Partner's Date Of Birth*

YYYY

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*