Formulaire de déclaration d'effet indésirable

Un effet indésirable est un événement grave indésirable et accidentel, y compris une maladie transmissible, qui se pose chez la receveuse ou l’enfant de donneur en relation avec l’usage du sperme de donneur.

Selon la directive européenne sur les tissus et les cellules et la directive danoise Vævslov les effets indésirables suspectés doivent être signalés immédiatement à SellmerDiers.

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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:*
Format de date :JJ slash MM slash AAAA
In which country did the insemination/treatment take place:*
Describe the suspected adverse reaction:*
File
Types de fichiers acceptés : word, pdf, jpeg, gif, tif.
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Terms of privacy policy*
- I’ve read and accept the terms of privacy policy

“ Je suis sûr que votre futur enfant vous apportera la joie et le bonheur. Citation par Banks “

Formulaire de déclaration d’effet indésirable

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

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