WP E-Signature by Approve Me - Sign Documents Using WordPress -

Clinical Release of Semen

Today's Date: May 20, 2026

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):

Anonymous Donor IUI / Intrauterine Insemination Vials (Gradient washed; 0.5cc volume)

Anonymous Donor ICI / Intracervical Insemination Vials (Unwashed; 1.0cc volume)

Anonymous Donor IUI / ICI Vials: ART / IVF / ICSI Quality

Directed Donor IUI Vials

Directed Donor ICI Vials

Sexually Intimate Partner IUI Vials

Sexually Intimate Partner ICI Vials

I Authorize waiving the recommended 6-month quarantine period for a Directed Donor

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. Additionally, the patient understands that by waiving the 6-month quarantine period it would subject them to inseminating potentially hazardous specimens as the testing may not show a new infection. 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.

Physician Name:

License Number:

State Issued:

Facility Name:

Office Address Line 1:

Office Address Line 2:

City:

State/Province/Region:

ZIP/Postal Code:

Country:

Phone:

Fax:

Website:

Contact Name:

Contact E-Mail:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signed by Sanjay Kumar
Signed On: October 18, 2025

Timestamp

Audit

May 24, 2021 9:38 pm CDT

Clinical Release of Semen Uploaded by Sanjay Kumar - none@ca.eightysevenweb.dev IP 2603:8098:1c00:15:69fc:74f:81d2:a737