IVF funding Application

SSIT assists people with spinal cord injury, enabling greater independence and quality of life.

After submitting your online application to us, please send an email to info@ssit.org.uk stating your name, and the date you applied. This will enable us to check that your online application has arrived safely; if we have not received it, we will be able to sort this out with you.

Personal Information

Title:*

Surname:*

Forename:*

Initals:*

Address:*

Postcode:*

Telephone:*

Mobile:*

Email:*

Date of Birth:*

Date of Injury:*

Injury Level:*

How did you hear about SSIT?:*

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

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.

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.

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.

Childlessness.

Couples will be eligible for support if they do not have a living child from their current relationship.

Sterilization.

Couples will not be eligible for support if either partner has been previously sterilized.

BMI.

Women must have a BMI between 19 and 29.9 inclusive for a period of six months before receiving treatment.

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:*

Consultant's full name:*

Consultant's address:*

Consultant's telephone:*