Fertility Solutions Consent Form

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By signing this document, you confirm you understand that:

Included in your semen analysis or DNA fragmentation test price is a copy of your results report. A discussion of your results is chargeable at a reduced fee. You are not obliged to follow any advice we offer or the recommendations that we make to you. Other fertility providers can interpret your fertility tests should you so wish.

The specific method used for assessing sperm DNA fragmentation levels may vary. 

If, following your discussion, you decide to see a urologist or fertility consultant, you will from this point be a patient of the referred consultant and it is your responsibility to discuss with that consultant their fees and charges.

Following any tests for which you were referred by a consultant, you must make an appointment to discuss these results with that consultant. Additional costs will be payable for this appointment.

You give consent to Fertility Solutions to correspond with your referring clinician or practice.

All semen samples are disposed of after testing and are not frozen for future clinical use.

Your semen analysis will be conducted by a suitability experienced embryologist or andrologist, who is externally assessed by NEQAS. 

Payment for diagnostic testing is required to secure your booking and is not refundable. This includes but is not limited to: if you have not followed our instructions with respect to periods of abstinence, if you cancel your booking with us. If the sample is not suitable for DNA fragmentation testing, a handling fee of £75 will be applied to your account and the remainder of the test cost will be refunded.

All medical reports are sent via the secure portal Egress.

You consent to Fertility Solutions using your personal data as per our privacy policy and terms and conditions. You consent to us sending your results by email.

While we have confidence in any consultant we refer to, this is only a recommendation as opposed to a specific endorsement of their abilities. You are advised to carry out due diligence on any specialist to which you entrust your care and treatment.

I HAVE READ FERTILITY SOLUTIONS' PRIVACY POLICY STATEMENT AND TERMS AND CONDITIONS CONTAINED WITHIN THEIR BOOKING SYSTEM AND AGREE TO ABIDE BY THEM.

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Date:

For patients having a post-vasectomy test only: When referred to the clinic for a semen analysis following vasectomy, Fertility Solutions acts in a diagnostic capacity only. The responsibility of the interpretation of your results and the efficacy of your procedure remains with the operating surgeon. Fertility Solutions cannot offer you clearance to cease the use of contraceptive methods.