Telford & Wrekin CCG FERTILITY SERVICES REFERRAL FORM

Female partner details
Surname: 

First name: 

All Previous Surnames:  	Title: 

Date of birth: 

NHS number: 	
Address: 

Post code: 

Home telephone number:  

Mobile number: 	Details of GP:  

Ethnicity: 
                   	Interpreter required:   Yes      No   
Language:      	
Name and details of referrer if not GP:
     

	Signature:	
1.  CRITERIA FOR ASSISTED CONCEPTION	
Is the female partner aged 40 or over at time of treatment?   	Yes   No 	
Does the couple have any children together in this relationship or previous relationship (Including adopted children)? 	Yes   No 	
Has either partner been sterilised or undertaken a reversal of sterilisation procedure?	Yes   No 	
Has the couple received one or more previous cycles of treatment?	Yes   No 	
Is the female’s BMI outside the NICE recommended 19-30 range?	Yes   No 	
Smoking status – does either partner smoke?	Yes   No 	
Has the couple been together less than 2 years?	Yes   No 	
Would you consider the couple unlikely to accept or comply with the demands of adhering to the treatment plan?	Yes   No 	
If the answer to one or more of the  questions above is ‘yes’, the patient may not meet the CCG’s  eligibility criteria for funded assisted conception- please refer to the fertility policy. T&W CCG Fertility Policy  Patients who do not meet the criteria for assisted conception should not be referred for investigation at NHS expense.	
In addition to complying with the above criteria, the patient/couple must conform to the Human Fertilisation & Embryology Authority’s (HFEA) Code of Practice concerning the welfare of the child.	
Cause of infertility if identified?      

OR How many years of unexplained infertility?      
	
Is the woman on folic acid?	Yes   No 	
3.  FEMALE INVESTIGATIONS TO BE COMPLETED BY GP PRIOR TO REFERRAL	
LH (day 2-7)	Date:      	Result:      	
FSH (day 2-7)	Date:      	Result:       	
Oestradiol (day 2-7)	Date:      	Result:      	
Rubella immunity	Date:      	Result:      	
Chlamydia screening	Date:      	Result:      	
Haemoglobinopathy screening (if req.)	Date:      	Result:      	
Other female information if available 	
Hepatitis B: 	Date:      	Result      	
Hepatitis C	Date:       	Result:      	
HIV: 	Date:       	Result      	
Pelvic Ultrasound	Date:      	Result      : 	
Hysteroscopy	Date:      	Result      	
Hysterosalpingogram	Date:      	Result      : 	
Cervical screening	Date:       	Result:       	
Male partner details
Surname:      

First name:      
	
Date of birth        Age:      

NHS number:      	
4.  MALE INVESTIGATIONS TO BE COMPLETED BY GP PRIOR TO REFERRAL	
Semen analysis 
(count, % motility, % abnormal forms)

	Date:      

	Result:      	
Other male information if available 	
Hepatitis B: 	Date:       	Result      	
Hepatitis C	Date:      	Result:       	
HIV: 	Date:      	Result      	
5. ANY OTHER RELEVANT INFORMATION	

	

Signature:	

Please read in conjunction with Telford & Wrekin CCG’s Fertility Policy. T&W CCG Fertility Policy
If your patient does not meet the criteria set out in the fertility policy and there are exceptional clinical reasons, please complete an individual funding request:  telford.ifr@nhs.net