Today's Date: November 21, 2023

Patient / Co-Parent Information

Patient Name: 

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.

Authorization

My patient has agreed to the terms above and that all specimens obtained are for her personal use only.

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Office Address Line 2: 

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Signed by Sanjay Kumar
Signed On: December 19, 2022

Signature Certificate

Document name: Clinical Release of Semen

Unique Document ID: df137d008a874ed9b0e136568059707a895991e7

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Timestamp	Audit
May 24, 2021 9:38 pm CST	Clinical Release of Semen Uploaded by Sanjay Kumar - [email protected] IP 104.62.148.28

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://cryobankamerica.com/

Audit Trail Serial# 562167bbf4c790c84b5a0f93bc38f5bc