Dextra Lapsettomuusklinikka Oy, Saukonpaadenranta 2, 4.krs 00180 Helsinki, puh 045 7733 9994 10-12-2013, Versio 1.0, Laatija KK / Hyväksyjä EV AGREEMENT ON TRANSPORTATION OF SPERM FROM ANOTHER CLINIC I / we agree on having the sperm that is stored for us at ______________________________________ (which clinic) transported to Dextra Fertility Clinic for storage and use. All documents containing information about the sperm, as well as results from the infection tests can be sent along with the sperm. I / we also give the sending clinic permission to inform the sperm bank about our personal details, if needed. The number of straws_________. The transportation is organized by Dextra Fertility Clinic. The clinic is not responsible for the possible destruction of the sperm during the transportation. A new storage agreement will be made for one year. Date:__________________________________ _____________________________________________ ________________________________________________ Name Name _______________________________________________ ___________________________________________ Social security number / date of birth Social security number / date of birth _______________________________________________ ___________________________________________ Tel. Tel. _______________________________________________________________________________________________________ Address _______________________________________________________________________________________________________ Signatures ____________________________________________ On behalf of Dextra Fertility Clinic ……………………………………………………………Klinikat täyttävät……………………………………………………………………….. KULJETUSTIEDOT Kuljetuksen lähetyspäivä ja kellonaika:_______________________________________________ Infektiokoevastaukset mukana: on/ei Tarvittavat dokumentit mukana: on/ei Kuljetussäiliö__________________________________________________________________________ _______________________________________________ Lähettävän klinikan kuittaus Kuljetus perillä vastaanottavalla klinikalla (päivämäärä ja kellonaika):_________________________ Onko kuljetus asianmukaisesti saapunut: on/ei Tarvittavat dokumentit mukana: on/ei Infektiokoevastaukset mukana: on/ei ________________________________________________________ Vastaanottavan klinikan kuittaus Lisätietoja:______________________________________________________________________________________________

agreement on transportation of sperm from another … Lapsettomuusklinikka Oy, Saukonpaadenranta 2, 4.krs 00180 Helsinki, puh 045 7733 9994 10-12-2013, Versio 1.0, Laatija KK / Hyväksyjä

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Page 1: agreement on transportation of sperm from another … Lapsettomuusklinikka Oy, Saukonpaadenranta 2, 4.krs 00180 Helsinki, puh 045 7733 9994 10-12-2013, Versio 1.0, Laatija KK / Hyväksyjä

DextraLapsettomuusklinikkaOy,Saukonpaadenranta2,4.krs00180Helsinki,puh0457733999410-12-2013,Versio1.0,LaatijaKK/HyväksyjäEV

AGREEMENTONTRANSPORTATIONOFSPERMFROMANOTHERCLINICI/weagreeonhavingthespermthatisstoredforusat______________________________________(whichclinic)transportedtoDextraFertilityClinicforstorageanduse.Alldocumentscontaininginformationaboutthesperm,aswellasresultsfromtheinfectiontestscanbesentalongwiththesperm.I/wealsogivethesendingclinicpermissiontoinformthespermbankaboutourpersonaldetails,ifneeded.Thenumberofstraws_________.ThetransportationisorganizedbyDextraFertilityClinic.Theclinicisnotresponsibleforthepossibledestructionofthespermduringthetransportation.Anewstorageagreementwillbemadeforoneyear.Date:__________________________________ _____________________________________________________________________________________________Name Name_______________________________________________ ___________________________________________Socialsecuritynumber/dateofbirthSocialsecuritynumber/dateofbirth__________________________________________________________________________________________Tel. Tel._______________________________________________________________________________________________________Address_______________________________________________________________________________________________________Signatures____________________________________________OnbehalfofDextraFertilityClinic……………………………………………………………Klinikattäyttävät………………………………………………………………………..KULJETUSTIEDOTKuljetuksenlähetyspäiväjakellonaika:_______________________________________________Infektiokoevastauksetmukana:on/eiTarvittavatdokumentitmukana:on/eiKuljetussäiliö_________________________________________________________________________________________________________________________ LähettävänklinikankuittausKuljetusperillävastaanottavallaklinikalla(päivämääräjakellonaika):_________________________Onkokuljetusasianmukaisestisaapunut:on/eiTarvittavatdokumentitmukana:on/eiInfektiokoevastauksetmukana:on/ei________________________________________________________ VastaanottavanklinikankuittausLisätietoja:______________________________________________________________________________________________