Treatment outcome submission

As part of HFEA regulation we have to submit the outcome of treatments to our regulators to help them monitor CRGW and ensure we maintain our success rates. It also enables an increased body of data to help inform other patients in the future. Your personal date will never be available to other patient but rather the statistics that arise from them. For instance if we treat 200 women who are 38 years of age, the submissions by these patients would help inform other patients of the same age what their chances would be by percentage of live birth. You can complete that data in a paper form which we can send to you or in the form below.

Treatment outcome form

Patient name*
First Last
Patient date of birth*
DD slash MM slash YYYY

Date of birth in format dd/mm/yyyy
Partner name (if applicable)
First Last
Patient date of birth (if applicable)
DD slash MM slash YYYY

Date of birth in format dd/mm/yyyy
Email*
Enter Email Confirm Email
Disclaimer*
- I recognise that CRGW cannot be responsible for the encryption and therefore cyber safety of sending documentation electronically without password protection. I have taken this advice into account given the nature of the documentation I have attached and acknowledge that CRGW recommend sending sensitive documentation via a password protected electronic system or via recorded delivery post or hand delivery.
Treatment outcome*
Number of babies delivered*
Weight (baby 1) in KG*
Weight (baby 2) in KG (if applicable)
Weight (baby 3) in KG (if applicable)
Sex (baby 1)*
Sex (baby 2) if applicable
Sex (baby 3) if applicable
Delivery date*
DD slash MM slash YYYY

Delivery date in format dd/mm/yyyy
Weeks of gestation at delivery*
Baby 1 name (First and Last)*
First Last
Baby 2 name (First and Last) if applicable
First Last
Baby 3 name (First and Last) if applicable
First Last
Place of birth / delivery*
Any abnormalities noted at birth?*
Baby’s NHS number(s) (if known)
Attach a document or image (if you need to)
Accepted file types: jpg, jpeg, png, gif.
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