Residential / Pick-Up Release of Authorization

My Virtual Physician is an option to do a telemedicine visit to get your clinic release form signed if you do not have or cannot find a licensed medical practitioner. Please use this link to schedule your appointment: https://hipaa.jotform.com/230546423115043

If you have any questions regarding their services, please reach out to them directly.
Phone: 888.224.0804
Email: info@myvirtualphysician.com
Website: https://myvirtualphysician.com/

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 referring

Patient's Name(Required)

Patient's Date of Birth:(Required)

to 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.

Print Name of LMP:(Required)

License Number:

Today's Date:(Required)

Hospital/Center Name:

Address

City

State

Zip Code:

Telephone Number:

Fax Number:

LMP Signature:(Required)

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: forms@seattlespermbank.com.

You may also mail them to:

Seattle Sperm Bank
4915 25th Avenue NE, Ste 204W
Seattle, WA 98105

Residential / Pick-Up Release of Authorization

AUTHORIZATION FOR RELEASE OF SEMEN - RESIDENTIAL DELIVERIES/PICK-UP

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