testing sad nofity me option


 

Today's Date: September 26, 2020

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.

 

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:

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Document name: testing sad nofity me option
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May 10, 2018 12:08 pm CDTtesting sad nofity me option Uploaded by Test Testing - haley@approveme.com IP 103.67.157.111