SHROPSHIRE & MID-WALES FERTILITY CENTRE
ROYAL SHREWSBURY HOSPITAL (NORTH)
SEMEN ANALYSIS REQUEST
PLEASE PERFORM A SEMEN ANALYSIS FOR THIS PATIENT
Male Patient Label
GP NAME
Unit no
ADDRESS
Name
D.O.B
ADDRESS
POST CODE
FEMALE PARTNER'S NAME/UNIT NO
POST CODE
/
TELEPHONE NUMBER
(home)
(work)
PRIVATE/NHS PATIENT * (Delete as appropriate)
REFERRING DOCTOR
DATE
CONSULTANT/REGISTERED GP
DATE OF PREVIOUS SEMEN ANALYSIS/SWIM UP
LENGTH OF SUB-FERTILITY
YEARS
MONTHS
CLINICAL DETAILS:-
DRUG THERAPY
TOBACCO
/day
ALCOHOL
units/week
LAB USE ONLY
INFERTILITY NUMBER
APPT. DAY
APPT. DATE
TIME
Please post this form to the Unit or fax it on 01743-261458
Andrology department Tel: 01743 261199
Authorisation date
01/05/2007 Review date
Author
SB
Number of pages
01/12/2008 Version number
1
Location
2
Document number
ISO9000 QUALITY\FORMS\ANDROLOGY
A1A