» 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 Born.

We thank you for your cooperation.

If you haven’t received a confirmation, or we haven’t contacted you within 72 hours, please contact us either by e-mail (sales@borndonorbank.dk and maja@borndonorbank.dk) or phone (+45 20 55 65 95) about your Adverse Reaction.

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 Born 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:*
Date Format: DD slash MM slash YYYY
In which country did the insemination/treatment take place:*
Describe the suspected adverse reaction:*
File
Accepted file types: word, pdf, jpeg, gif, tif.
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Terms of privacy policy*
- I’ve read and accept the terms of privacy policy

“ I’m sure that you will be the right parents and give the little new baby, love, care and all opportunities in life. Quote by 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