Clinic Release Form - Seattle Sperm Bank

AUTHORIZATION FOR RELEASE OF SEMEN - CLINIC DELIVERIES ONLY

This form authorizes the patient to transport shipments directly to our clinic address.

I am referring

Patient's Name(Required)

Patient's Date of Birth(Required)

to the 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