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MEDICAL EVALUATION To be completed by the physician. Patient s Applicant s Name Patient s Partner s Co-Applicant s Name Length of Infertility FEMALE EVALUATION Medical Problems and/or Infertility Diagnosis Surgical History Please briefly describe the patient s likelihood of conceiving without medical intervention with minimal medical intervention basic therapy and likelihood of conceiving with IVF. What is your recommendation for treatment for this patient Please make note of any additional...

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