RAMQ DONOR SPERM ORDER FORM

This form is only for Quebec patients who are ordering under the RAMQ Medically Assisted Reproduction Program.   

After this order form is submitted, CAN-AM will confirm with your clinic that you are eligible for the RAMQ program. Order shipment may be delayed while we await this confirmation. Please see THIS PAGE for more information.

PATIENT INFORMATION:

Patient Name:*

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

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

DayMonthYear

Patient RAMQ#:*

RAMQ Confirmation*

RAMQ eligibility confirmed by clinic ____

Type a question

Patient Phone #:*

Patient Email:*

example@example.com

Patient Street Address:*

Patient City*

Patient Province*

Patient Postal Code:*

ORDER INFORMATION:

RAMQ covers up to $850 per vial.

Current vial prices can be found here:
https://www.canamcryo.com/en/donor-sperm-egg-fee-guide

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

DayMonthYear

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

DayMonthYear

*CAN-AM will ship at any time before this date unless specified otherwise.

Orders shipping within 24hrs of order completion (order, informed consent, clinic confirmation, payment) may be subject to a $95 (+tax) RUSH ORDER FEE.

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.

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

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 information on the donor's profile.

SHIPMENT INFORMATION:

RAMQ covers up to $100 per shipping fee.

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:*

This is the physician who will be performing the insemination

Clinic Name (if applicable):*

Clinic City:*

Clinic Province:*

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

19-SEP-2022 CAN-AM DONOR SPERM ORDER FORM - RAMQ Ver. 01