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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:

Prescription for Semen Analysis

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

Masturbation

Condom

Other

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?

Yes

COLLECTION AT LABORATORY?

Yes

*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?

Yes

DID ANY PART OF THE SAMPLE MISS THE SPECIMEN CONTAINER?

Yes

*If YES, do you still want the laboratory to perform the semen analysis?

Yes

TYPE OF SPECIMEN CONTAINER (COLLECTION CUP) USED:

Plastic

Condom

Glass

Other

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

Self

Partner

Other

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

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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New York Cryo https://nycryo.com

Timestamp

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March 5, 2018 10:05 pm EDT

Specimen Production Form Uploaded by Bruce Gilbert - labstaff@nycryo.com IP 24.187.203.26