Patient Form and Brochure Center

SPERM BANKING (STORING YOUR OWN SPECIMENS) FORMS AND BROCHURES

Brochure

• CLI Sperm Banking Brochure (Requires Adobe Acrobat Reader)

• Semen Depositor Agreement
• Off Site Collection Documentation
• Collection & overnight shipping instructions
• Billing Agreement
• Storage Patient Information
• Patient Questionnaire
• Medical Tests for Cryopreservation

FORMS FOR TERMINATION OF CONTRACT

• Termination Request Form

FORMS FOR SPECIMEN RELEASE TO PHYSICIAN (Please Call to Place Order)

• Authorization to Release Medical Information
• Request for Release of Specimens
• Physician Account Set Up (Note: check with customer service at 800-466-2796 to see if your physician already has an account set up with CLI)
• Ordering Authorization (Note: Optional if owner would like another person to be able to order specimens from his account)