*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
Please do not fill out the fields below.
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.