Fertility Referral

Dear Tas IVF	Date

Thank you for seeing:
Patient name Patient address
Date of birth	Phone number
Patient email (if possible)

Partner name

Please review my patient for: (please tick)
Fertility assessment	Fertility treatment
Ovarian reserve testing	Semen analysis

Partner date of birth

Ovulation Tracking Recurrent miscarriage

Intrauterine insemination (IUI) Ovarian tissue freezing
Egg donation Other:

Medical History:

Ovulation induction Egg freezing
Sperm donation

In vitro fertilisation (IVF) Sperm freezing Surrogacy

TasIVF51 05.10.2023

REMINDER:
Please ask your patient to bring all relevant medical reports and scans to their appointment.
Your patient will be contacted by our patient liaison officer to make an appointment.

Referring Doctor:
Name Address
Phone	Provider No.

Please email to admin@tasivf.com.au ◆  1800 111 483 ◆  tasivf.com.au

TasIVF
Network & collective strength

Dr Manuela Toledo
T 6212 7700

Dr Steve Sonneveld
T 9885 2112

Dr Emily Price
T 6220 1350

PRIMARY CONSULTING LOCATION	Hobart Fertility Clinic 2 Melville Street, Hobart	Hobart Fertility Clinic 2 Melville Street, Hobart	Hobart Fertility Clinic 2 Melville Street, Hobart	
ADDITIONAL LOCATIONS		16 Clare Street, New Town		

Dr Warren Kennedy
T 6212 7700

Dr Ben Dhanaraj
T 6332 2000

PRIMARY CONSULTING LOCATION	Hobart Fertility Clinic 2 Melville Street Hobart	Launceston Fertility Clinic Queen Victoria Tower
11 High Street East Launceston	
ADDITIONAL LOCATIONS			

tasivf.com.au | 1800 111 483