Instructions:

*Please follow the instructions sheet for sample collection

*Fill out the upper portion of this form and hand it to the receptionist together with your semen sample cup

*MAKE SURE THAT THE SPECIMEN CUP IS LABELED WITH YOUR NAME

*Required Field

*Patient's Name (Male):
 
Patient's Date of Birth:
Patient's Home Phone:
Partner's Name (Female):
Referring Doctor:
Referring Doctor Phone:
Date:
Time Collected:
Today's specimen collected at:
Today's Specimen:
Number of days abstinence (from intercourse or masturbation):
Was the sample collected in the container (Sterile cup or Condom) supplied by our office?
If no what type of container was?
Was part of the sample lost?
Was the sample exposed to extreme heat or cold?
Was any lubricant used?
If so, what?
Are you taking any medication other than what was prescribed by Dr. Peress?
If so, what?
Have you had any illness or fever within the last three months?
If so, what?

Please do not fill out the fields below.

Lab Staff Only

Semen sample recieved by:
Time received:
Analyzed by:
Time of Analysis:
Testing Delayed or Cancelled:
Reason:

Payment is due at the time of service. If you wish to know the fee for any service in advance of scheduling, please fell free to ask the receptionist. By typing you initials in the box below you agree to accept the terms of our fees policies.

Patient Initials: