Fertility referral completion form

Name of GP being seen (see information sheet given in appointment)

Female first name

Female surname

Female date of birth

Please use format day/month/year e.g. 12/05/1979

Partner first name

Partner surname

Partner date of birth

Please use format day/month/year e.g. 12/05/1979

Partner address

City

Partner address

Postcode

Female to confirm:

I’ve had my progesterone blood test taken before my period

My GP told me I also needed the hormone blood test taken during my period – and I’ve had this done

My GP told me I didn’t need the hormone blood test taken during my period

I’ve returned my chlamydia and gonorrhoea self-swab to the Practice (recommended but not essential)

I’ve chosen not to send a chlamydia and gonorrhoea self-swab

I’ve provided the dates of my MMR vaccinations to the Practice, if I’ve had any

You can add the dates of your MMR vaccinations here if you haven’t already provided them

Please use format day/month/year e.g. 12/05/1979

Please tick as applicable

Male partner has provided a semen sample to the Edinburgh Fertility Centre

NA – same-sex female couple

(Partner to tick) I consent to my name, date of birth and address being included on the fertility treatment referral form

Partner signature

Clear

We’d be grateful if you could give us some feedback on how you found the process of arranging a fertility referral.

Do you have any other feedback you'd like to give about the fertility referral process, once you'd arranged the initial appointment to discuss fertility referral?

If you are human, leave this field blank.

Fertility referral completion form

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