Donations in memory of Horatio Chapple will fund an accessible garden at the Duke of Cornwall Spinal Treatment Centre.

Donations in memory of Horatio Chapple

People with spinal cord injury are encouraged to apply to SSIT for help with the provision of equipment needed to promote independence and good health.

Please help us continue our work providing equipment and facilities for the Duke of Cornwall Spinal Treatment Centre and assisting people with spinal cord injury living in the region.

IVF funding application

Click here to download this form as a blank PDF for you to complete by hand.

 

Please complete the following form, all items marked with * are required.

Personal Information

Initials:*
Date of Birth:*
NHS Number:*
PCT:*

 

Southern Spinal Injuries Trust Criterion for Access to Financial Support for Sperm Retrieval and Intracytoplasmic Sperm Injection Treatment

Please note that we are unable to fund any other part of IVF treatment.

ref Title Criterion Tick if Yes
1* Age of woman at time of cycle starting. The time of the cycle of IVF starting for the first time should be after the woman’s 26th birthday and before her 40th birthday.
2* Age of woman at time of referral to tertiary care from secondary care. The age limit will be restricted to 26 to 39 years inclusive.
3* Previous infertility treatment. Couples will be eligible for support if they have not already received three cycles of IVF treatment in line with evidence from NICE guidelines.
4* Childlessness. Couples will be eligible for support if they do not have a living child from their current relationship.
5* Sterilization. Couples will not be eligible for support if either partner has been previously sterilized.
6* BMI. Women must have a BMI between 19 and 29.9 inclusive for a period of six months before receiving treatment.
7* Smoking. Both partners must be non-smokers for at least six months before receiving treatment.

 

Cost of treatment and authorisation

Cost of treatment you are requesting SSIT to fund:* £   (write as 100.00)
Date you need SSIT’s decision by:* (write as DD/MM/YYYY)
Consultant's full name:*
Consultant's address:*
Consultant's telephone:*