ReproMed Booking Form

Which Hub do you wish to visit?*

—Please choose an option—ReproMed DublinReproMed Galway

Which SDF test do you wish to book?*

—Please choose an option—ExactExtend (referral required)

Do you wish to drop off your sample or produce it at the clinic?*

—Please choose an option—Sample Drop OffProduce Sample at Clinic

Please confirm the name of the man providing the sample for the test*
First Name*
Last Name*

Email*

Phone Number

Street Address #1*

Street Address #2

City*

Postcode*

Country*

If you have selected an Extend test, you must confirm you have a referral letter and that you will send it to lab@examenlab.com – we cannot send out a payment link to progress your test without it.

I confirm that I have a referral letter for my Extend test.

In order to respond to your enquiry, we need to store and process your personal data ourselves and also share it with our hub partner ReproMed so that they can contact you to arrange your test booking. If you consent to us storing and sharing your personal data for these purposes, please tick the checkbox below.

I agree to allow Examen to store and process my personal data, and to share it with ReproMed.*