Sperm Bank Service Forms

Below is a complete list of forms you might need to complete if you would like to use one of our services. Please find the service you are interested in and open the patient forms for that service. You may either save the fill-in forms on your hard drive and then complete on your computer or fill them out online and send them via email. Don’t forget to read any instructions applicable to the services you are choosing.

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. Click here for detailed instructions on how to fill-in your information on the forms. 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

For Donating Sperm

• Instructions for Semen Sample Collection
• Online Donor Application (Currently not available because of high volume of new applications. Please check back August/September 2008)
• Consent to Donate Semen (Sperm)
• Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy Practices

For Using Donor Sperm

• Registration Form
• Donor Match Form Recipient Information
• Physician’s Authorization to Release Frozen Semen for ICI/IUI
• Authorization for Perform IUI
• 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 Profile
• Directed Donor Specimen Ownership Form
• Consent and Agreement to Perform Artificial Insemination Using Sperm from a Known Donor
• Authorization for Perform IUI
• Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy Practices
  

Sperm Cryopreservation (Sperm Freezing), Storage and Transfer

• Patient Registration Form (Short Term and Long Term Storage)
• Consent & Agreement for Cryopreservation and Storage of Semen
• Consent & Agreement for Storage of Sperm From Another Sperm Bank
• Notice and Consent for AIDS-Related Blood Testing
• Consent and Agreement for Pending Lab Results for Storage of Semen (Use if outside lab is used)
• Ultimate Disposition of Semen Specimens
• Notice of Intent to Continue or Discontinue Storage
• Physician’s Authorization to Release Frozen Semen for ICI/IUI
• 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
• Form to Discontinue Storage (Notarized signature required) - Please contact our office to receive this form

Embryo Cryopreservation (Embryo Freezing) and Storage

• Registration Form
• Consent and Agreement for Cryopreservation and Storage of Embryos
• Notice of Privacy Practices
• Acknowledgement of Receipt of Notice of Privacy Practices

Gender/ Sex Pre-Selection

• Sex Pre-Selection Consent Form
• Sex Pre-Selection Patient History
  

 

 

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