Clinic Release

Seattle Sperm Bank requires an Authorization For Release of Semen be on file when samples are shipped to your home, picked up from our office, or if you are a NY State resident.

This form must be filled out by your Physician or an authorized representative of the clinic. For residents of the State of NY, this form MUST be completed by the recipient’s physician, physician assistant, or nurse practitioner for all orders.

This form can be printed, signed by your doctor, and faxed to: (206) 466-4696 or scanned and emailed to

Clinical Release PDF

We can send an electronic version of this form to your Physician/Clinic. Please provide the following information: