Deposition of a Known Semen Donor Cryopreservation at the Department of Growth and Reproduction

Information regarding the referral of a known sperm donor for cryopreservation at the Department of Growth and Reproduction, Rigshospitalet, in connection with treatment at the Fertility Clinic, Rigshospitalet.

Date: ___________________

Donor’s name

CPR number

Donor’s signature

Woman’s name

CPR number

Woman’s signature

The above-mentioned man is referred for semen cryopreservation as a known sperm donor.

Additional information:

Previous urogenital diseases:

Other medical conditions:

Medication:

Referring physician: