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
Patient Location
Please select...
England
Scotland
Wales
Northern Ireland
Republic of Ireland
Which clinic are you under the care of?
If you have already had a genetic counselling session, please upload your signed Igenomix Test Requisition Form.
Preferred donor's Seattle 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 Seattle 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
Seattle 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
Seattle
Sperm Bank to request this.
Donor 3’s
Seattle 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
Seattle
Sperm Bank to request this.
Donor 4’s
Seattle 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
Seattle
Sperm Bank to request this.
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