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Thank you for your enquiry.
Please explain briefly why you have contacted us and complete the questionnaire.

Questionnaire

First Name

Last Name

Email Address

Please select your gender

Your age: in Years

Do you have any medical conditions? No Yes

If yes, name them:

Questionnaire for males

Have you had any other children? No Yes

Have you seen a urologist No Yes

Has any reason been found to explain your infertility? No Yes

If yes, please elaborate:

Have you ever had a semen analysis or sperm tests? No Yes

Any additional comments?

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T: 041-3741134 • F: 041-3738541
M: 082 652 4520
pdal@iafrica.com

T: 041-3743974 • F: 041-3743978
M: 082 787 4841
dbotha@medi.co.za

(Postal & Physical)
Ground Floor
St George's Medical Suites
40 Park Drive
Central, Port Elizabeth
T: 041-3730771 • F: 041-3742006