UBC In Vitro Fertilization Program

The UBC Centre for Reproductive Health
at Women's Health Centre D6

4500 Oak Street Street
Vancouver, BC
Canada, V6H 3N1
T: 604-875-2445 F: 604-875-2569

How to make an appointment
Sections 1, 2 and 3 of this form may be filled in and given to your doctor who may complete the form and make a referral by faxing it to us at: (604) 875-5124. You can use the "Print" button at the bottom of this form, or just use the "Print" button in your browser .
We will contact the patient directly with appointment time.

Section 1
PATIENT’S FIRST NAME:
SURNAME:
DATE OF BIRTH:
AGE:
CARE CARD#:
Section 2
PARTNER’S FIRST NAME:
SURNAME:
DATE OF BIRTH:
AGE:
CARE CARD#:
ADDRESS:
CITY:
PROVINCE:
POSTAL:
TELEPHONE: HOME:
PATIENT WORK:
PARTNER WORK:
Section 3
REFERRING PHYSICIAN:
	OB/GYN GP BILLING #:
ADDRESS:
CITY:
PROVINCE:
POSTAL:

If this referral is to a specific clinic physician, please indicate here:	Dr.

(if left blank, an appointment will be arranged)
Has the patient been here before?	Yes No
Do they speak and understand English?	Yes No
If No, please have patient bring an interpreter to their appointment.
How long have they been trying to conceive with their current partner?

SERVICE REQUESTED: Please note that previous infertility testing is not required prior to a patient being seen at the clinic. Please indicate whether the referral is for an initial infertility work-up and/or for a specific type of treatment.
Endocrine Assessment	Male Factor Infertility
Menopause	Endometriosis
Initial Infertility Workup	Ovulation Factor
Tubal Factor	In Vitro Fertilization (IVF)
Intrauterine Insemination (IUI) with Partner’s sperm	Age Criteria < 44 years old
Other:	Intracytoplasmic Sperm Injection (ICSI)

MEDICAL RECORDS: If a previous work-up has been done, please append copies of relevant information.
Female Partner:	Hysterosalpingogram
	Operation Reports (eg. laparoscopy, hysteroscopy)
	Consultation reports
	Lab Reports (eg. hormonal assays, rubella)
Male Partner:	Semen analysis
	Urological Consultation Reports