DONOR SPERM ORDER FORM 17-SEP-2020 Rev. 03

Complete this form in its entirety to prevent delays in the shipment of your order. If you have questions about this form or your order, please contact us by email or by phone.

PATIENT INFORMATION:

The "patient" is the individual who will be inseminated.

Patient Name: *

Patient Date of Birth (dd/mm/yy): *

Day Month Year

Patient Phone #: *

Patient Email: *

example@example.com

Patient Street Address: *

Patient City *

Patient Province *

Patient Postal Code: *

ORDER INFORMATION:

Date of order (dd/mm/yy): *

Day Month Year

Latest date to arrive at clinic (dd/mm/yy):

Day Month Year

PLEASE NOTE:

We request FOUR (4) BUSINESS DAYS to process completed orders (new or from storage). Orders are not considered complete until we have received: the order, payment, terms of use and informed consent/ acknowledgment of genetic risk (if required).

Any orders shipped with less than four (4) business days notice may be subject to a rush order fee IF it is possible to ship.

Sperm Bank: *

Fairfax/ CLI NW Cryobank Seattle Sperm Bank

1st choice donor: *

# units of 1st choice donor: *

Vial type of 1st choice donor: *

IUI (prewashed) ICI (unwashed)

Your clinic can tell you whether they have a preference of vial type. "Washed" donor vials have been processed at the sperm bank before freezing and can be used for intrauterine insemination (IUI) directly after thawing. "Unwashed" vials can be used for intracervical insemination (ICI) or may be washed at your clinic prior to being used for IUI.

Both prewashed and unwashed vial types may be suitable for IVF procedures.

2nd choice donor (if applicable):

# units of 2nd choice donor:

Vial type of 2nd choice donor:

IUI (prewashed) ICI (unwashed)

3rd choice donor (if applicable):

# units of 3rd choice donor:

Vial type of 3rd choice donor:

IUI (prewashed) ICI (unwashed)

SHIPMENT INFORMATION:

Complete this section if you would like any units shipped from CAN-AM to your clinic or physician's office right now.

Current shipping fees can be found here:
https://www.canamcryo.com/en/shipping-fees

# units to ship to clinic or physician's office

Physician Name:

Clinic Name (if applicable):

Clinic City:

Clinic Province:

STORAGE INFORMATION:

Complete this section if you would like any units to be stored at CAN-AM until you are ready to have them shipped to your clinic or physician's office.

The current storage fees can be found here:
https://www.canamcryo.com/en/purchasing/storage-fees

# of units to be stored at CAN-AM

Storage term:

Monthly - billed automatically 1 Year prepaid 3 Years prepaid 5 Years prepaid

CAN-AM's Terms & Conditions and CAN-AM's Privacy Policy

*

I have read and agreed to CAN-AM's Terms & Conditions and to CAN-AM's Privacy Policy

The End

17-SEP-2020 CAN-AM DONOR SPERM ORDER FORM Rev. 03