Application Form Life A&V

"CHOOSE LIFE A&V" INTERNATIONAL PROGRAM APPLICATION

Welcome to the Choose Life A&V medical support registry (Vancouver, Canada). Please complete the following steps carefully to submit your formal clinical intake request.

Applications are reviewed after the registration fee has been completed.

STEP 1: APPLICANT DETAILS

  1. Full Name (Exactly as shown in your international passport): [ ___________________________ ]
  2. Date of Birth (DD/MM/YYYY): [ ____ / ____ / ___________ ]
  3. Country of Actual Residence: [ ___________________________ ]
  4. City: [ ___________________________ ]
  5. Email address: [ ___________________________ ]
  6. Primary Contact Number (WhatsApp/Telegram): [ ___________________________ ]
  7. Preferred language of communication: [ ___________________________ ]

STEP 2: FERTILITY HISTORY

  1. Have you been officially diagnosed with clinical infertility?
    [ ] Yes
    [ ] No
  2. Type of infertility:
    [ ] Primary infertility (never conceived)
    [ ] Secondary infertility (conceived before)
    [ ] Not specified by my doctor
  3. Diagnosed cause of infertility (as stated by your doctor):
    ____________________________________________________________________________
    ____________________________________________________________________________
  4. How many years have you been trying to conceive? [ __________ ]
  5. Previous treatments (IVF, IUI, surgery, hormonal therapy, etc.) and their results:
    ____________________________________________________________________________
    ____________________________________________________________________________
  6. Number of previous pregnancies / miscarriages, if any: [ __________ ]

STEP 3: GENERAL HEALTH

Please check any chronic conditions you manage:

  • [ ] Diabetes (Type 1 or 2)
  • [ ] Bronchial Asthma
  • [ ] Cardiac Disease
  • [ ] Epilepsy / Seizures
  • [ ] Severe or anaphylactic allergies
  • [ ] None

Other chronic conditions (please specify):
____________________________________________________________________________
____________________________________________________________________________

Current medications you take regularly (name and dosage):
____________________________________________________________________________
____________________________________________________________________________

STEP 4: LEGAL DECLARATIONS & CONSENT

  • [ ] I confirm that I will provide the official Choose Life A&V Physician Form covering at least the last 6 months of active medical history records.
  • [ ] I grant voluntary consent to Choose Life A&V to transfer my screening and medical data to a licensed Canadian medical Doctor.
  • [ ] I grant voluntary consent to my treating physician and medical institution to disclose and release my medical records, test results and clinical information to Choose Life A&V for the purposes of this application.
  • [ ] I confirm that all information provided above is accurate and complete to the best of my knowledge.

Signature: _______________________   Date: ____ / ____ / ___________

After your registration is completed, you will receive the official Choose Life A&V Physician Medical Stability Form. Your treating physician must complete it in English, sign it, and place an official clinic stamp, covering at least the last 6 months of your clinical history.