Sample Referral Form for Doctors

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					     HARI Unit, Rotunda Hospital, Parnell Sq., Dublin 1
                             Tel: 01 8072732 - Andrology Dept.
                          Semen Analysis Request Form

To be filled in by referring Doctor :
(Please write clearly using BLOCK capitals as this is the address to which the results will be returned)
Doctors Name / Surname : _________________________                          Tel :_______________________
Address:______________________________________                              Fax:_______________________
___________________________________________________________________
Client Details (if possible attach an addressograph label)

First Name / Surname :____________________________                          DOB: _____________________

Tel No:.____________________ Partners First Name/ Surname:______________________

Address :___________________________________________________________________

Clinical Details :
1.       Previous SA Test results :                 Normal ❏              Abnormal ❏           Not applicable ❏
If abnormal, please include details of abnormality and where test was performed below:
.
………………………………………………………………………………………………………………………………………………………………

2.       History of recent illness / current treatment / medication/ known infection risk
………………………………………………………………………………………………………………………………………………………………


To be filled in by Client (after sample collection)
     Date : ……/……../……..                                    Time of collection of sample:……………….
     Did you take this sample at : Home ❏                   HARI Unit ❏                      Elsewhere ❏
     Period of abstinence from ejaculation (from intercourse/masturbation):……. (days)
     Is this the first sample that you have produced for this clinic ?      Yes ❏            No ❏
     Did you spill any of the sample during collection ?                    Yes ❏            No ❏
     Did you have any difficulty producing this sample?                     Yes ❏            No ❏

If there is any information you would like to add which you feel may be relevant to the interpretation of your result,
please write this on the other side of this page.

I confirm that the name and date of birth on both this form and on the sample container relate to me and are
accurate. I understand that if there is any discrepancy between these and the form I have completed that my
sample will not be processed.
                       Signed :………………………………….                        Date:…………………………………..


Lab use only :
      Date and Time Received:……/……/……                        ………….am/pm             Lab A / No…………………

				
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