beREADY Order Form
Ordering
IVF clinic ordering code
Doctor
E-mail
Tube ID (5 digits)
Patient’s name or initials
Date of birth
Please include InvisibleMi+ endometrium microbiome (clients with contract)
Yes
No
Please include InvisibleMi+ vaginal microbiome (clients with contract)
Yes
No
Diagnoses and the number of previously failed IVF cycles, other comments
Date of biopsy
Time of biopsy
Biopsy
1st
2nd
3rd
4th
HRT
NA
+3
+4
+5
+6
+7
+8
Progesterone intake (date)
Progesterone intake (time)
hCG
NA
+5
+6
+7
+8
+9
hCG intake (date)
hCG intake (time)
LH
NA
+5
+6
+7
+8
+9
LH peak detection
Hereby I confirm that the patient has been informed about the test outcome and possible complications of the endometrial biopsy sampling. I confirm that the patient has signed informed consent.
Please upload Patient Informed Consent form pdf ONLY if agreed previously by beREADY team
