Patient Forms
Download and Submit Patient Forms to FCC
Below is a complete list of patient forms for the Fertility Center of California. Please find the fertility service you are interested in receiving and complete the corresponding patient forms. You may either save the fill-in forms to your hard drive and then complete on your computer, or fill them out online and send them to forms@fertilityctr.com. Please read the instructions carefully and fill out the form accordingly.
Please note: To view, complete and print FCC fill-in PDF forms you'll need the freely available Adobe Reader software installed on your computer. If you do not have Adobe, click here.
General Forms
- Registration Form
- Authorization to Release Laboratory/Medical Records
- Pregnancy Report Form
- Notice of Privacy Practices
- Acknowledgement of Receipt of Notice of Privacy Practices
- Reproductive Material Release Form
For Donating Sperm
- Instructions for Semen Sample Collection
- Online Donor Application
- Consent to Donate Semen (Sperm)
- Notice of Privacy Practices
- Acknowledgement of Receipt of Notice of Privacy Practices
For Using Donor Sperm
- Registration Form
- Agreement for Using Donor Sperm
- Notice of Privacy Practices
- Acknowledgement of Receipt of Notice of Privacy Practices
For Directed Donor Program
- Registration Form
- Directed Donor Specimen Ownership Form
- Consent and Agreement to Perform Artificial Insemination Using Sperm from a Known Donor
- Notice of Privacy Practices
- Acknowledgement of Receipt of Notice of Privacy Practices
Sperm & Reproductive Tissue Cryopreservation, Storage and Transfer
- Patient Registration Form (Short Term and Long-Term Storage)
- Consent & Agreement for Cryopreservation and Storage of Semen
- Agreement to Transfer Reproductive Materials To FCC
- Addendum to Cryostorage of Reproductive Materials Agreement Infectious or Potentially Infectious Disease
- Consent and Agreement for Pending Lab Results for Storage of Semen (Use if outside lab is used)
- Reproductive Material Cryostorage Agreement
- Notice of Intent to Continue or Discontinue Storage
- Specimen Release Form (Specimen to be sent to your physician)
- Tank Rental Agreement (Use of our tanks for transportation)
- Notice of Privacy Practices
- Acknowledgement of Receipt of Notice of Privacy Practices
- Tank Rental Agreement for Specimen Transfer
- Medical History
- Agreement to Transfer Reproductive Materials From FCC
- Form to Discontinue Storage (Notarized signature required) - Please contact our office to receive this form
Embryo Cryopreservation, Storage and Transfer
- Registration Form
- Notice of Privacy Practices
- Acknowledgement of Receipt of Notice of Privacy Practices
- Agreement to Transfer Reproductive Materials To FCC
- Medical History
- Reproductive Material Cryostorage Agreement
- Agreement to Transfer Reproductive Materials From FCC
Gender/ Sex Pre-Selection
Where should I send my completed forms?
Completed forms can be printed out and brought to the office or emailed in advance to forms@fertilityctr.com.
