Fees and Forms

Physician Forms 

• Requisition Order
• Requisition for Sperm Preparation
  

Patient Forms 

• Fee Schedule & Policy
• Ovulation Timing by LH Kit Testing
• Sample Collection Instructions
• Genetic History Questionnaire
• Male Health History Questionnaire
• Female Health History Questionnaire
• Donor Consent Form

The following forms require a witness for your signature: 

• Semen Storage Agreement
• Donor Semen Storage Agreement

Print a form and fill it out - do not sign it, yet!
If you DO appear in person at the Andrology Laboratory, you may have a UUHSC staff member "witness" your signature.
If you DO NOT appear in person at the Andrology Laboratory (e.g. you will be mailing in your request), have your signature notarized (you can do this at most banks).

Release of Medical Information 

• Privacy Practices Policy

The University of Utah Health Science Center follows the Federal requirements for protection of your personal medical information. If you would like the University of Utah Health Sciences Center to share (or receive) your medical health information with anyone (spouse, family member, other health care provider, etc.) you must give written permission. Please use the Patient Authorization Disclosure or Receipt of Protected Health Information form to give permission. Please read and complete the entire form.

Please note: your signature must be witnessed by a UUHSC employee or a Notary Public.