Clinic Release - Authorization For Release of Semen
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 signed electronically by your Physician, printed and faxed to (206) 466-4696, or scanned and emailed to forms@seattlespermbank.com.
NY State Resident
For recipients undergoing treatment in the state of NY, the Authorization For Release of Semen MUST be completed by the recipient’s physician, physician assistant or nurse practitioner for all orders. This form is required to be on file before we can ship any vials to NY State.
Home Shipments & Lab Pickups
We require the Authorization For Release of Semen to be completed by the recipient's physician, physician assistant, or nurse practitioner for all orders that are being delivered to a home or picked up from one of our Lab Locations.