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
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
DOB: Your Date of Birth
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”):
DIAGNOSIS OR REASON FOR TEST:
List any transport issues or state None:
RELATIONSHIP: Relationship to Patient
Name (if other than Patient):
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
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Specimen Production Form
Agree & Sign