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.

FOR QUEBEC PATIENTS ONLY:

QUEBEC PATIENTS: Do not complete this form if you are trying to order through the RAMQ MAR program for donor sperm.

Complete this form instead: QUEBEC RAMQ ORDER FORM

PATIENT INFORMATION:

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

Patient Name:*

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

DayMonth 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):*

DayMonth Year

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

DayMonth Year

PLEASE NOTE:

We require 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.

*Orders must be shipping within 2 weeks or storage fees will apply

IMPORTANT: Please confirm availability of your chosen donor by calling 1-888-245-3471 or emailing info@canamcryo.com BEFORE placing this order.

Sperm Bank:*

Fairfax/ CLINW CryobankSeattle 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)

GENETIC TESTING

The number of genetic mutations that our donor sperm suppliers are testing for is increasing. This means that it is becoming more common to see donors that are known carriers of one or more genetic conditions.

Please check the genetic test results for your donor, and complete an informed consent if your donor is a known carrier of one or more genetic conditions. We cannot process this order until we have this form. Contact CAN-AM if you have any questions about finding this inormation on the donor's profile.

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

QUEBEC PATIENTS: Do not complete this form if you are trying to order through the RAMQ program for donor sperm.

Complete this form instead: QUEBEC RAMQ ORDER FORM

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 automatically1 Year prepaid3 Years prepaid5 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

Please verify that you are human*

The End

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