After cancer / gonadotoxic treatment • Merrion Fertility Clinic

After cancer / gonadotoxic treatment referral form

Please provide as much relevant information as possible, including medical reports and documentation, to avoid delays.

Survivors of Childhood Cancer

Referrals can be made by completing the online referral form below or via your GP or Consultant.

*Please provide as much relevant information as possible, including medical reports and documentation, to avoid delays.

Details:
First Name:*
Last Name:*
Current Age:*
Social issues of concern*
Accessibility Issues:*
eg: Wheelchair
Diagnosis:
Age at diagnosis:*
Underwent fertility preservation prior to treatment:*
- Yes
- No
Site of fertility preservation:*
Date of completion of medical treatment:
Date of last cancer treatment (Radiation):
Include Fields / Dose (if possible)
Date of last cancer treatment (Chemotherapy):
Include Protocol / dose / last dose
Date of last cancer treatment (Surgery):
Medical Documents

Medical documents / Letter to confirm diagnosis and treatment (please add age at treatment).
Referring Physician*
Referring Practitioner address:*
Referring Practitioner email address:*
Referring Practitioner phone number:*
The concept of fertility preservation and the reason for this referral has been discussed and explained to the patient:*
- Yes
- No
If Yes, please provide Consultant details*
GP Details

Please forward letter of fitness regarding suitability for fertility preservation (egg freezing).
GP's Name:*
GP's email address:*
GP's phone number:*
Parent / guardian contact mobile number:*
Parent / guardian contact email address:*
Is patient currently under surveillance:*
- Yes
- No
Medical Documents File Upload*
Drop files here or

Max. file size: 50 MB, Max. files: 5.
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