Clinical Release of Semen
Today's Date: April 11, 2021
Patient / Co-Parent Information
Partner/Spouse or Co-Parent Name:
Patient Date of Birth:
Partner/Spouse or Co-Parent Date of Birth:
Preferred Semen Specimen Type for Release
(Please select all that apply):
I am referring to Cryobank America, to obtain semen specimens for an assisted reproductive procedure or for use in at-home insemination. I have informed the patient named above, of the risks and limitations of said patient’s procedure and have authorized the patient to obtain the specimens from Cryobank America.
My patient understands that there are inherited risks and limitations of the patient’s procedure, and that genetic or infectious disease screening can reduce this risk, but understands and acknowledges that the risk cannot be eliminated entirely. This form is valid for two (2) years from date listed above.
My patient has agreed to the terms above and that all specimens obtained are for her personal use only.
Office Address Line 1:
Office Address Line 2:
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Your legal name
Your email address
Signed by Mike Blaine
Signed On: January 27, 2021
If you have questions about the contents of this document, you can email the document owner.
Document Name: Clinical Release of Semen
Agree & Sign