Patient Full Name
Patient Date of Birth
Patient Email Address
Will anyone else require testing?
Yes - (partner)
No
Partner Full Name
Partner Date of Birth
Partner Email Address
Preferred donor's Xytex Sperm Bank ID/number
Preferred donor’s genetic test report
If you do not already have a copy of your donor’s genetic test report, please contact Xytex Sperm Bank to request this.
Are you interested in having testing against additional donors?
Yes - 1 additional donor
Yes - 2 additional donors
Yes - 3 additional donors
No
If you are interested in testing against more than 4 donors please upload the reports for your top 4 donors and then get in touch with
gc.uk@igenomix.com
to provide details for the remaining donors.
Donor 2’s
Xytex Sperm Bank ID/number
Donor 2’s genetic test report
If you do not already have a copy of your donor’s genetic test report, please contact Xytex Sperm Bank to request this.
Donor 3’s
Xytex Sperm Bank ID/number
Donor 3’s genetic test report
If you do not already have a copy of your donor’s genetic test report, please contact Xytex Sperm Bank to request this.
Donor 4’s
Xytex Sperm Bank ID/number
Donor 4’s genetic test report
If you do not already have a copy of your donor’s genetic test report, please contact Xytex Sperm Bank to request this.
Yes, I agree to the
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