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Semen Analysis Request Form (AND-FM-000195V3)

Semen Analysis Request Form

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jjj681843
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43 views2 pages

Semen Analysis Request Form (AND-FM-000195V3)

Semen Analysis Request Form

Uploaded by

jjj681843
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Centre for Reproductive Medicine

Semen Analysis Laboratory


Request Form

Please complete section below Hospital: Ward: Patient’s Surname: NHS Number:
(see important information
overleaf)
Date of sample production: Consultant: Patient’s Forename(s): Hospital Number:

......... / ……… / ……… NHS PP

Patient’s Dob:
Time of sample production: GP Name:
:
GP Address: Patient’s Address:
Was any of the sample lost?

Yes No

Number of days since last Report to (please tick): Partner’s Surname: Hospital / NHS Number:

Ejaculation GP Consultant
Partner’s Forename(s): Partner’s Dob:

IT IS ESSENTIAL THAT YOU BRING THIS FORM WITH YOU FOR YOUR APPOINTMENT

Routine Tests Appointment Details:

Investigations Required Viral Status

Standard Fertility Semen HIV Positive


Analysis

Post orgasmic urine Hepatitis B Positive Clinical Details:


analysis
Hepatitis C Positive
Semen Cryopreservation

Unscreened
Post vasectomy semen
analysis Bloods taken on:

Is this: …………………………………….

First Repeat Comment:


Test Test

At the Centre for Reproductive


Medicine Please highlight the existence of any known increased risk of
transmissible infection this sample may pose to the laboratory

Author: A O’Neill/S Turner This document is not controlled if printed


Document Location: QM computer, I drive (reporting forms)
Reference: Quality/reporting forms/semen analysis request form Version: AND-FM-000195V3 Review Date: March 2024
Revision History: April 2020 (no changes), March 2022 (amends)
Centre for Reproductive Medicine

Semen Analysis Laboratory


Request Form

IMPORTANT INFORMATION

APPOINTMENTS (Appointments are from 9 am to 3 pm, Monday to Friday)

An appointment is required to deliver a semen sample for analysis. Samples will not be accepted
without an appointment.

To arrange an appointment, or raise a query telephone the Andrology Laboratory, Centre for
Reproductive Medicine on:

(024) 76 968873

SEMEN PRODUCTION

Your semen sample MUST be produced at home. It MUST arrive at the laboratory within 60
minutes of production and be kept at body temperature in transit.

The semen sample should be collected by masturbation making sure ALL the fluid is collected
into the sterile container you have been provided. If any of the sample is lost please note this
on your form or on the sample container.

Your semen sample must be collected under conditions of cleanliness. We therefore ask that
you wash your penis thoroughly with water before producing the specimen.

We strongly recommend a 2-3 day period of sexual abstinence prior to producing any
specimen for analysis. This will make sure that we are provided with the best quality sample
possible. It is not advisable to abstain for any longer than 7 days as this may reduce the
quality of your semen sample.

IT IS ESSENTIAL THAT YOU:

1) Label your specimen pot clearly with your name and date of birth.
2) Fill in the form completely. It is essential that the shaded area is completed.
3) Return your sample as directed, at your appointment time. Samples arriving late will
not be processed.

Author: A O’Neill/S Turner This document is not controlled if printed


Document Location: QM computer, I drive (reporting forms)
Reference: Quality/reporting forms/semen analysis request form Version: AND-FM-000195V3 Review Date: March 2024
Revision History: April 2020 (no changes), March 2022 (amends)

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