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, please contact us via the patient portal.

Self Referral Form

Please indicate the reason for your referral*
Merrion Fertility Clinic is not currently accepting Egg Freezing referrals due to an unprecedented demand for the service over the past few months. We are very sorry for this inconvenience but hope to resume this service for new patients as soon as possible.
If necessary, please provide more detail.
Forename*

As stated on passport
Known As
Maiden Name (if applicable)
Surname*
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 ever attended MFC for a doctor consultation?*
GP Name and Address*
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
Partner's Contact Number*
Partner's Email*
Partner's First Language*
Partner's Nationality*
Partner's Occupation*
Partner's GP Name and Address
Are you trying to conceive?*
When did you start trying to conceive?*
How many days is your menstrual cycle? (if applicable)
Date of last menstrual period

Day
Month
Year
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.
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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