Andrology (Semen Analysis) Referral Form

Andrology (Semen Analysis) Referral Form

Please note to enable us to deal with all referrals in a timely manner, we ask that all sections of this form are completed.

This Person Needs Support with their Appointment

Please indicate any communication support you use when interacting with this person:

Spoken Language Interpreter British Sign Language Interpreter

Communicator Guide for people with dual sensory loss

Other eg. Learning Disability (Please state language and dialect or other support needed in the space below)

Date Of Referral:
Name / Previous name
Date of Birth
/ Age / NHS Number
Address / Telephone / Home:
Mobile:
Alt. No:
Name of Referrer / Surgery Phone:
Surgery Fax:
Surgery Address / Practice Code:
Ethnicity / Interpreter Required? / Y/N / If Y specify language:
War Veteran ? / Y/N
Special Requirements? If yes please state:
(eg Hearing Loop, Wheelchair Access,)
Ambulance required? If yes please select:
Stretcher Walking 2nd Man Escort required for medical reasons
Reason for Referral :
Primary Infertility: Secondary Infertility:
If secondary infertility please provide further information:
Relevant condition/medication:
Previous analysis:
None: Newcastle Fertility Centre:
Elsewhere: (Please provide details)
NOTE: PLEASE ADVISE PATIENT TO ABSTAIN FROM SEX OR EJACULATION FOR 2-7 DAYS PRIOR TO THEIR APPOINTMENT.

Please return form to:

Newcastle Fertility Centre, Biomedicine West Wing, International Centre for Life, Time Square, Newcastle upon Tyne, NE1 4EP.

Reception Tel No: 0191 2138213

Fax No: 0191 2138214

NFC/Letter/23– Version 1 Date Active: 20May2014 Last printed 17-Jan-14 Page 1 of 2