Referral for Sperm Cryopreservation for Adolescent and Young Adults (YF1.4 FP) • Merrion Fertility Clinic

Patient First Name*

Patient Last Name*

Weight (kg)*

Height (cm)*

Date of Birth*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Patient Guardian/NoK*

Phone Number*

Email Address*

Referring Physician*

Email Address*

Date of Referral*

Social issues of concern*

Accessibility Issues (e.g., Wheelchair)*

Medical Pathway

Diagnosis*

Medical Concerns*

Assessment of impact on future fertility*

Chemotherapy*

Yes
No

Potentially gonadotoxic*

Yes
No

Start date*

Agents*

Radiotherapy*

Yes
No

Treatment (Radiotherapy)*

Pelvic
Non-pelvic

Start date*

Surgery*

Yes
No

Treatment (Surgery)*

Pelvic
Non-pelvic

Start date*

HSCT*

Yes
No

Start date*

Other therapy*

e.g., hormonal, immunotherapy, etc

Yes
No

If Yes, please give details*

Start date*

I have discussed the potential impact of treatment on fertility with the patient and parents/guardians*

Yes
No

I have provided information / link to information leaflet on sperm freezing*

Yes
No

Parent(s)/Guardian(s) permission to have discussion re: sperm production*

Yes
No

The concept of sperm production has been explained to the patient*

Yes
No

Named Consultant*

Referring Practitioner*

Referring Practitioner address*

Referring Practitioner email address*

Referring Practitioner phone number*

Relevant Information

ie: anaesthetic sheets, results etc

Drop files here or

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Consent*

I confirm that I have read and understand the statement below.

When you submit this form, your information will be reviewed and an appointment will be made for you. Your appointment details and information can be accessed by logging in to our online patient portal (you will receive a link to register). Should you have any queries or if the appointment date does not suit, please contact us.

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