Consent Form

NAME:

By signing you agreed to abide by the terms and conditions of the clinic and confirm that you understand that:

Included in your semen analysis/DNA fragmentation test price is a copy of your results report and a discussion of your results. You are not obliged to follow this advice or the recommendations that we make to you. Other fertility providers can interpret your fertility tests if you should so wish. A discussion of your results is not designed to replace a consultation with a gynaecologist or urologist.

If following your discussion you request a referral to a urologist or gynaecologist you will from this point be a patient of the referred consultant and it is your responsibility to discuss with the consultant their fees and charges.

Following any tests recommended by a consultant you will need to make an appointment to discuss these results with your consultant, you understand that additional costs will be payable for this appointment.

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

All semen samples are disposed of after testing and are not frozen for future use unless sperm freezing has been specifically arranged.

Your semen analysis will be conducted by a suitability experienced embryologist/andrologist externally assessed by NEQAS.

Payment for diagnostic testing is required to secure your booking and is not refundable under any circumstances whatsoever. This due to the costs that are incurred by the clinic upon appointment confirmation. This includes but is not limited to: if the sample produced on the day is not suitable for testing, if you have not followed our instructions for periods of abstinence or if you cancel your booking with us.

All medical reports are sent via the secure portal egress with no exception if you are unable to open your report a copy will be posted to your home address.

You consent to allow Fertility Solutions to use your personal data as per our privacy policy and terms and conditions. To enable us to send you your results by email we require your consent to do this.

Fertility solutions reserves the right to cancel a clinic in this event an alternative appointment will be made.

Whilst we have confidence in any consultant that we refer to you this is a recommendation only and not an endorsement of their abilities. You are advised to carry out due diligent on any specialist individual or clinic to which you entrust your care and treatment.

Due to the recent pandemic fertility services following your tests are likely to be delayed.

In respect to the pandemic regulatory guidelines from a number of governing bodies have been followed however you understand that you enter the hospital at your own risk.

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

Signed:

Date:

For patients having a vasectomy only When you are referred to the clinic for a semen analysis following vasectomy, fertility solutions act in a diagnostic capacity only. The responsibility of the interpretation of your results and the efficacy of procedure remains with the operating surgeon. Fertility Solutions cannot offer you clearance you will need to make an appointment with your operating consultant to discuss this. We advise contraceptive measures in the meantime.