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 homepicked 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

Online Form – Authorization For Release of Semen

Print Form – Authorization For Release of Semen – PDF

Forward Authorization

Please fill out your Name, Email Address, and Dr Information and we will forward the form to the specified e-mail address of your Dr/Clinic