Donor Sperm Backorder form

Donor Sperm Backorder form
102 & 202 - 1057 Main St W Hamilton ON L8S 1B7

info@canamcryo.com www.canamcryo.com
Please note: This is NOT an official order and does not obligate you to purchase. This form places you on our waiting list and allows us to contact you when/if we receive units of your desired donor so that you have an opportunity to purchase before they are listed as available. You will be given 5 business days from the time of initial contact to respond and let us know if you are still interested. If we do not hear back from you, we will simply cancel your backorder.
PATIENT INFORMATION:
Name: *
Date of birth (dd/mm/yy): *

Day Month Year
Email: *
example@example.com
Phone: *
BACKORDER REQUEST:
Date (dd/mm/yy): *

Day Month Year
Supplier: *

Fairfax/CLI Seattle Sperm Bank NW Cryobank
Donor ID: *
Approximate # of units: *
Prep preference (select all that apply): *

IUI ICI IUI ART ICI ART
*IUI – prewashed (intrauterine insemination), ICI – unwashed (intracervical insemination), ART – suitable for IVF/ICSI
Have you achieved a pregnancy or birth from using this donor in the past? *

yes no
Comments (optional):
CLINIC INFORMATION:
Physician Name: *
Clinic (if applicable): *
City: *
CAN-AM's Terms & Conditions and CAN-AM's Privacy Policy
*

I have read and agreed to CAN-AM's Terms & Conditions andto CAN-AM's Privacy Policy
CAN-AM Backorder Form V2 Effective 17-JUL-20
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