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Semen Analysis Requisition Form

Semen Analysis Requisition Form

Instructions:

*Please follow the instructions sheet for sample collection
*Fill out and print before submitting 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
*Required Field

Today's specimen collected at
Today's Specimen
Was the sample collected in the container (Sterile cup or Condom) supplied by our office?
Was part of the sample lost?
Was any lubricant used?
Are you taking any medication other than what was prescribed by Dr. Peress?
Have you had any illness or fever within the last three months?


Please do not fill out the fields below
Lab Staff Only


Payment is due at the time of service. If you wish to know the fee for any service in advance of scheduling, please feel free to ask the receptionist. By signing in the box below you agree to accept the terms of our fees policies




875 Meadows Road Suite 334, Boca Raton, FL 33486
Phone: (561) 368-5500 | eMai:FrontDesk@BocaFertility.com



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