AUTHORIZATION FOR RELEASE OF SEMEN - RESIDENTIAL DELIVERIES/PICK-UP
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.I am referringto Seattle Sperm Bank, to obtain semen specimens for an assisted reproduction procedure.
Licensed Medical Practitioner (LMP) to sign and complete entire form below.
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.
I/We 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.
The patient has agreed that all specimens obtained from the cryobank are for their personal use only.
Please keep a copy for your records.
The above forms can either be faxed to our office fax number: (206) 466-4696 or emailed to: firstname.lastname@example.org.
You may also mail them to:
Seattle Sperm Bank
4915 25th Avenue NE, Ste 204W
Seattle, WA 98105