Adverse Reaction Report Form

An adverse reaction is a serious inadvertent adverse event, including a transmittable disease, that arises in the recipient or in the donor child in connection with the use of donor sperm.

According to the EU Tissues and Cells Directive and the Danish Vævslov suspected adverse reactions must be reported immediately to SellmerDiers.

We thank you for your cooperation.

Adverse Reaction Report Form

INFORMATION ABOUT THE PERSON REPORTING THE ADVERSE REACTION
Name and title of the reporting Health Care Professional*
Address Line (Clinic Name, Street Name and Number)*
City/Town*
Postal Code*
Country*
Telephone Number*
E-mail*
INFORMATION ABOUT THE ORDER AND THE DONOR SPERM
Order Number*
Obtained from SellmerDiers when the order was placed
Donor Name*
Ejaculate Number*
Unique donation number found on the sperm unit
Sperm Preparation Type/Method of treatment*
Did the clinic that treated the recipient do any processing of the donor sperm prior to the treatment?*
- Yes
- No
INFORMATION ABOUT THE ADVERSE REACTION
Who developed the adverse reaction?*
- The recipient
- The live-born donor child
- The unborn donor child (late-stage abortion, stillborn)
Date of the treatment with the donor sperm:*
Datumsformat:TT Schrägstrich MM Schrägstrich JJJJ
In which country did the insemination/treatment take place:*
Describe the suspected adverse reaction:*
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Akzeptierte Datentypen: word, pdf, jpeg, gif, tif.
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Terms of privacy policy*
- I’ve read and accept the terms of privacy policy

“ Ich wünsche dir und deinem Kind eine freudige Zukunft. Zitat von Armstrong “

Adverse Reaction Report Form

Adverse Reaction Report Form

INFORMATION ABOUT THE PERSON REPORTING THE ADVERSE REACTION

INFORMATION ABOUT THE ORDER AND THE DONOR SPERM

INFORMATION ABOUT THE ADVERSE REACTION