Authorization For Release of Semen


I am referring (patient’s name)   (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.

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:  
Date Signed:   November 25, 2020
Hospital/Center Name:  
Address:   
City/State/Zip Code:  
Telephone Number:  
Fax Number:   

 

Please keep a copy for your records.

 

LMP Signature*:

Leave this empty:

Signature arrow
Signature Certificate
Document name: Authorization For Release of Semen
lock iconUnique Document ID: 6fbc7c5b1b3a6cc95634a1b28f3e7f819f7ea3f4
Timestamp Audit
March 20, 2020 1:40 pm PSTAuthorization For Release of Semen Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 73.42.152.24