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X | : Andrology (Semen Analysis) Referral Form
Please note that to enable us to deal with all referrals in a timely manner,
we ask that all sections of this form are completed.
Results will be sent via ICE results should be available in the clinical letters - not lab reports. If you cannot receive them, please let the Centre know and we can make alternative arrangements for reporting.
Patient information leaflets and useful information to help you interpret results can be found on our website: APP Fertility Centre Departments Semen analysis.Date Of Referral:Name:Previous name:Date of birth:
Age:NHS/MRN number:Address:Telephone
APP:
Mobile:
Alt. No: Name of referrer:Surgery phone:
Surgery address:Practice code:Ethnicity:Interpreter required? FORMCHECKBOX
Please specify language:
This person needs support with their appointment FORMCHECKBOX
Please state support required (e.g., Hearing Loop, British sign language interpreter, Wheelchair Access, support for learning disability):
Reason for Referral:
Primary Infertility: FORMCHECKBOX Secondary Infertility: FORMCHECKBOX
If secondary infertility, please provide further information:
Relevant condition/medication:
N.B. We do not accept viral positive samples (HIV, Hep B/C etc.) as GP referrals, these patients must be referred to NFC for a special appointment and processing.
Previous analysis:
None: FORMCHECKBOX APP Fertility Centre: FORMCHECKBOX
Elsewhere: FORMCHECKBOX (Please provide details)
NOTE: PLEASE ADVISE PATIENT TO ABSTAIN FROM SEX OR EJACULATION FOR 48 HOURS - 7 DAYS PRIOR TO THEIR APPOINTMENT.
Please return form to:
APP Fertility Centre, Biomedicine West Wing, International Centre for Life, Time Square, APP upon Tyne, NE1 4EP.
Reception Tel No: 0191 2138213
PAGE 1
NFC/Letter/23 V4 Page PAGE 2 of NUMPAGES 2
NFC/Letter/23 V4 Page PAGE 2 of NUMPAGES 2
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