Application for semen for clinics Complete the form below to proceed with the request. This step is essential to facilitate the medical assistance process and meet your specific needs. Date of request: Date of treatment: Treatment selection (R.A. Technique)*—Please select an option—ICSI - Price: 250 €FIV - Price: 350 €IAD (1 dat) - Price: 400 €IAD (2 days) - Price: 500 €Training (1 day) - Price: 300 €Training (2 days) - Price: 600 € Information concerning the applicant Date of birth: Country*United Kingdom Ireland Albania Andorra Angola Anguilla Antarctica Antigua and Barbuda Armenia Aruba Australia Austria Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Chad China Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Cuba Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Iran Iraq Isle of Man Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Norway Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United States of America United States Virgin Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Height* Weight* Sanguine Group*—Please select an option—AB0AB RH*—Please select an option—PositiveNegative Ethnicity*—Please select an option—WhiteBlackLatinOther Aspect*—Please select an option—AthleticEthnicLeptosomic Hair color*—Please select an option—BlackBrownBlondRedhead Texture*—Please select an option—SmoothWavyCurly Skin*—Please select an option—BrunetteClarePale Eyes*—Please select an option—BlackBrownBlueGreenish Without a partnerWith male partnerWith female partner Información relativa a la pareja Date of birth: Height* Weight* Sanguine Group*—Please select an option—AB0AB RH*—Please select an option—PositiveNegative Ethnicity*—Please select an option—WhiteBlackLatinOther Aspect*—Please select an option—AthleticEthnicLeptosomic Hair color*—Please select an option—BlackBrownBlondRedhead Texture*—Please select an option—SmoothWavyCurly Skin*—Please select an option—BrunetteClarePale Eyes*—Please select an option—BlackBrownBlueGreenish Partner information Date of birth: Height* Weight* Sanguine Group*—Please select an option—AB0AB RH*—Please select an option—PositiveNegative Ethnicity*—Please select an option—WhiteBlackLatinOther Aspect*—Please select an option—AthleticEthnicLeptosomic Hair color*—Please select an option—BlackBrownBlondRedhead Texture*—Please select an option—SmoothWavyCurly Skin*—Please select an option—BrunetteClarePale Eyes*—Please select an option—BlackBrownBlueGreenish DI would like confirmation by*—Please select an option—PhoneEmail I have ordered more times Children born from our bank I would like to receive information on new treatments and news from Clinica Tambre. I have read and accept the privacy policy Together with this request for banked semen, the receiving centre will be responsible for carrying out and reporting the obstetric follow-up of each pregnancy for the control of the pregnancies of the Mistral Fertility Center Sperm Bank in accordance with the provisions of LAW 14/2006, of 26 May, on assisted human reproduction techniques. The amount must be paid by bank transfer to the account number ES35 0081 5243 42 0001860087 (Sabadell) in the name of Mistral Fertility Clinics, S.L. indicating your full name. You must also send the bank receipt, at least two days in advance, to the following e-mail address: administracion@clinicatambre.com
