Semen analysis referral request form

Semen analysis form

Has your partner already attended an initial appointment to discuss a fertility referral, and the GP agreed they meet the criteria for referral?

Yes

Please don’t complete this form at this point.

The female partner needs to have attended an initial GP appointment to discuss fertility referral and the GP agreed that they meet the criteria for referral, for us to refer the male partner for semen analysis.

You can come back and complete this form when this is the case.

Are you registered as a patient at Riverside Medical Practice

Yes

Please don’t complete this form – contact your own Practice to arrange a referral for semen analysis.

You then need to let us know that you’ve provided a sample in our online fertility referral completion form – a link to this will be provided at the initial appointment.

After the online completion form is submitted, the GP at Riverside will send the main referral for fertility treatment.

Name of GP seen (see information sheet given at appointment)

Your first name

Your surname

Your date of birth

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

Address

House number or name

Street name

Address

Town or city

Postcode

Your partner’s first name

Your partner’s surname

Your partner’s date of birth

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

I consent to my name, date of birth and address being included on the main fertility referral form

I agree that I want the Practice to send a referral for me to have semen analysis

If you are human, leave this field blank.

Semen analysis referral request form

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