Online Consultation

Please fill the Form below and use the ‘Pay Now’ button to pay INR 1000 /$15 for processing the Online Consultation.

General Information
Female Partner
(First & Last Name)
DD-MM-YYYY
Kgs
Ft _______ In ______
Male Partner
(First & Last Name)
DD-MM-YYYY
Kgs
Ft _______ In ______
Contact Details
Marital Information
Duration of Marriage
Years
Trying to Conceive Since
Years
Have you ever had Children?
No
Yes
If Yes, Please provide Details of Previous Pregnancy
Menstrual History
Last Menstrual Period
Last Period Date
Nature of Cycle
Irregular
Regular
If Irregular, Please describe the Irregularity
Medical History - Female Partner
Previous Abdominal Gynaecological Surgeries?
No
Yes
Previous Medical History
No
Yes
Choose Appropriate
Thyroid Condition
Diabetes
Hypertension/High Blood Pressure
Tuberculosis
Genital Tract Infection
Other(s)
Investigations - Female Partner
In case of previous Investigations related to Infertility Or General Gynaecology, Are any of the Reports Abnormal?
No
Yes

HSG

HSG (Hysterosalpingograhy) Done?
No
Yes

Hysteroscopy

Hysteroscopy Done?
No
Yes

Laparoscopy

Laparoscopy Done?
No
Yes
Medical History - Male Partner
Any Regular Use of
Tobbaco
Smoking
Substance Abuse
Previous Medical History
No
Yes
If Yes, Choose Appropriate
Diabetes
Hypertension/High Blood Pressure
Tuberculosis
Other(s)
For Others Please mention Details Here
Surgerical History
Varicocoele
Hernia
Other(s)
If Other(s) please mention Details Here

Semen Analysis

Semen Analysis Done?
No
Yes
Submit Form
Any Special Note
 
Please carefully select the payment option you would like to go ahead with:
We charge INR 1000/$15 for our Online Consultation.
Please use the 'Pay Now' button to make the payment.
Your Consultation Request will be processed after successful payment.
Disclaimer: The Online Consultation provided is to the Best of our abilities and understanding of the clinical situation based on the information provided by you. It in NO manner can replace a consultation and examination in person.