Semen Analysis Referral

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How to make an appointment

A GP letter of referral is required if you wish to make a semen analysis appointment. If you have a GP referral, please attach it to this form or, alternatively, your doctor can complete and stamp our semen analysis Request Form. It is essential that you follow the guidelines on the this form to ensure the most accurate results.

Results will be processed within 10 days. Results or copies of the results are not sent directly to the patient.

Semen Analysis Form

Forename*
Surname*
Date Of Birth*

DD
MM
YYYY
Address
Street Address Address Line 2 City County Eircode
Contact Number*
Email Address*
Enter Email Confirm Email
Partner Forename

If applicable
Partner Surname

If applicable
Partner Date Of Birth

DD
MM
YYYY
Do you have health insurance?*
Please note that if you are a VHI member, you may be entitled to benefits for fertility investigations, which are given to you directly by the clinic.
Select your health insurance provider.*
Enter your health insurance provider.*
Policy Number*
Doctors Name*
Doctor's Contact Number
Doctors Address
Street Address Address Line 2 City County Eircode
Is this an Initial or Repeat Semen Analysis Test?*
Have you been ill or taken prescribed medication in the last two months?
Any additional Details?
Have you had a semen analysis in another fertility clinic within the last year?*
If yes, please attach a copy below or provide a copy prior to your appointment.
Please upload your GP referral and any previous semen analysis test results
Drop files here or

Max. file size: 20 MB, Max. files: 5.
How did you hear about Merrion Fertility Clinic?*
Other website*
Other*
Consent*
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Semen Analysis Referral

How to make an appointment

Semen Analysis Form

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Semen Analysis

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