Forms for patients and donors

Patient and partner registration forms
(registry form)

 

What the forms are for:

To record the registration of new fertility treatment patients, and their partner, at your clinic.

The forms can also be used to make changes to a registered patient/partner’s details.

Patients and partners are registered separately, but are linked through patient numbers on the form.

Downloads:

 

Consent variation forms
(registry forms)

 

What the forms are for:

This form should be used for the following:

  • When patients and partners who were registered before 1 October 2009 buttreated after 1 May 2010 complete a CD form (N.B: for patients registered and treated after 1 October 2009, clinics should submit a correction to their original
    registration form rather than completing this CV form)
  • When parents consent to or object to the disclosure of information about their child but only when that differs from their preferences regarding disclosure of their own data.
Downloads:

Donor information form
(registry form)

What the forms are for:

A Donor information form must be completed for all sperm or egg donors including surrogacy commissioning couples and those registered separately as a patients.

If the donor has taken up the option of adding a goodwill message for any children born as a result of their donation they can do so on pages 3 and 4 of this form.

The information contained on pages 1 and 2 of this form should be submitted to the HFEA via EDI before the rest of the form is sent in by post for scanning into the register.

You can also print this form (including pages 3 and 4) from your EDI application.

Downloads:

 

Donor re-registration form
(registry form)

What the forms are for:

This form should be used if you have a donor who donated before April 2005 as an anonymous donor and would like to re-register to become identifiable.

The B form records the contact details for the donor and must be signed by the donor. You should verify the identiy of the donor and submit copies of this document.

The form should also be sent to the HFEA for submission into the Register which enables us to flag the donor as identifiable.

Downloads:

 

Welfare of the child form

 

What the forms are for:

This form should be completed by each patient requesting any licensed treatment or any unlicensed treatment which involves the handling or manipulation of gametes outside the body.

In surrogacy arrangements, both the commissioning couple and the surrogate (and her partner, if she has one) should complete this form. 

Downloads:

 

Intention to treat (ITT) forms
(registry form)

 

What the forms are for:

An intention to treat (ITT) form records an agreement to commence stimulation. This form is only for treatment cycles where there is an intention to collect eggs.

It should be completed and sent within three calendar days of the administration of stimulatory drugs or, in the case of natural unstimulated cycles the date of the last menstrual period where there is an intention to collect eggs from a patient.

The ITT form is not required for cycles where eggs are not to be collected e.g. frozen embryo transfers or donor insemination.

Downloads:

 

IVF treatment form
(registry form)

 

What the forms are for:

This form should be completed and sent to the HFEA after each one of the following events have occurred:

  • Ovarian stimulation starts with the intention of creating embryos 'in vitro'.
  • Gametes are mixed with the intention of creating embryos.
  • Embryos are used in treatment or removed from storage for treatment or donation.
  • Eggs are collected or embryos created are frozen and stored.
  • Eggs are collected or embryos created are donated for use in treatment or research.
Downloads:

 

Donor insemination treatment form
(registry form)

 

What the forms are for:

This form records the commencement of donor insemination treatment (DI). The form can also be used to amend the details on an existing DI treatment.

Downloads:

 Mitochondrial donation registration and treatment forms

What the forms are for: Forms for registering new mitochondrial donors, sperm donors for PNT only and treatment cycles involving mitochondrial donation.
Downloads:

Page last updated: 30 October 2015