Clinic Release Form

Authorization For Release of Semen

I am referring

Patient's Name:*

Patient's Date of Birth (DOB):*

to the Seattle Sperm Bank, to obtain semen specimens for an assisted reproduction procedure.

* For recipients undergoing treatment in the state of NY, this form MUST be completed by the recipient’s physician, physician assistant or nurse practitioner for all orders. Licensed Medical Practitioner (LMP) to place initials or checkmark next to one of the options below.

Checkboxes Clinic Release*

This form authorizes the patient to receive the donor specimens directly; either through delivery to their home address or by picking it up from Seattle Sperm Bank and its affiliates.

This form authorizes the patient to transport shipments directly to our clinic address.

I understand that every pregnancy has about 3 to 4% risk of producing a child with a birth defect or mental retardation. The life-time risk for all genetic disorders is higher. Genetic screening can reduce this risk to some extent, but it cannot eliminate the risk entirely.

My patient has agreed that all specimens obtained from the cryobank are for her personal use only.

Print Name of LMP:*

License Number:*

Today's Date*

Hospital/Center Name:*

Address:*

City/State/Zip Code:*

Telephone Number:*

Fax Number:*

Please keep a copy for your records.

LMP Signature*:

LMP Full Name*

LMP Email Address*

LMP Signature:*

Name

This field is for validation purposes and should be left unchanged.