Specimen Production Form
MENS FERTILITY LABORATORY – NY CRYO – BRUCE R GILBERT MD PhD PC
SEMEN SPECIMEN PRODUCTION FORM
THIS FORM NEEDS TO BE COMPLETED AND A PRESCRIPTION FOR THE TEST PRESENT IN THE LAB PRIOR TO YOUR SPECIMEN BEING ANALYZED. PLEASE SEE SEMEN SPECIMEN PRODUCTION AND TRANSPORTATION INSTRUCTIONS PRIOR TO PRODUCING AND TRANSPORTING YOUR SPECIMEN. IF YOU HAVE ANY QUESTIONS PLEASE CALL US AT 516-487-2700.
If you have not yet sent us your prescription for the test please upload the prescription from your healtcare provider:
Please complete the following information:
DATE: Today’s Date
PATIENT NAME:
DOB: Your Date of Birth
EMAIL ADDRESS:
LAST 4 DIGITS OF YOUR SS#:
………………………………………………………………………………………………………
METHOD OF COLLECTION: Method of Collection
TIME OF COLLECTION:
DAYS SINCE LAST EJACULATION:
*If a period of abstinence is less than 48 hours (2 days) or greater than 72 hours (3 days), do you still want the laboratory to perform the semen analysis?
COLLECTION AT LABORATORY?
*If not, where was specimen produced?
*If the Lab receives the sample more than 2 hours after it is produced, do you want the specimen analyzed, understanding that the prolonged time might affect the results?
DID ANY PART OF THE SAMPLE MISS THE SPECIMEN CONTAINER?
*If YES, do you still want the laboratory to perform the semen analysis?
TYPE OF SPECIMEN CONTAINER (COLLECTION CUP) USED:
SPECIMEN CUP PROVIDED BY LAB?
*If not, where did you obtain specimen cup?
CURRENT MEDICATIONS YOU ARE TAKING (If no meds enter “None”):
REFERRING MD:
DIAGNOSIS OR REASON FOR TEST:
List any transport issues or state None:
RELATIONSHIP: Relationship to Patient
Name (if other than Patient):
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For internal use only:
Reporting Lab: ___________Patient Number: ____________ Photo ID Verified: ___________
Time received: ___________ ID Form: __________________ Technician: _______________ Laboratory Director: Bruce R Gilbert MD PhD
Medical Director: Bruce R Gilbert MD PhD
My signature on this form acknowledges that this semen specimen is a product of the Patient’s body indicated on this form. I have reviewed and agree to the terms of service and privacy policy on the website at https://nycryo.com/terms-of-service-and-privacy-policy/. In addition, I acknowledge that if the specimen is lost, destroyed or for any other reason cannot be analyzed, NY Cryo’s liability is limited to the amount paid for the service.
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Document Name: Specimen Production Form
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