SEMEN ANALYSIS RECORD AND INSTRUCTIONS

PLEASE COMPLETE, SIGN AND RETURN THIS FORM WITH YOUR SAMPLE

INSTRUCTIONS FOR PRODUCING YOUR SAMPLE FOR TESTING
Please follow these instructions as failure to do so may render the results invalid and you will still be charged for services provided.

Clearly label the pot with your name and date of birth.

• Abstain from ejaculation for a minimum of 48 hours prior to producing the sample for testing, but not longer than 5 days.
  • Produce the semen sample into a clean sterile pot by masturbation. The pot may be obtained from your doctor or from a pharmacy.
  • Ensure that ALL the sample is collected into the pot. If part of the sample spills, please notify staff.
  • Produce the sample within 1 hour of your appointment and deliver it directly to the clinic for testing.
  • Keep the sample warm during transportation to the clinic by placing the pot containing your sample in your trousers or jacket pocket.

Referred by/ Treating Doctor: ……………………………………………..
Male Full Name: …………………………………………………………………..
Date of Birth: ………………………………………………………………………
Female Partner’s Name: ………………………………………………………
Female Partner’s Date of Birth: ……………………………………………
Number of Days Since Your Last Ejaculation: ………………………

Declaration: I declare that the sample provided is my sample. I understand and acknowledge that the results of semen analysis for the same individual can vary greatly from ejaculate to ejaculate and that the results from this test are for information only and represent sperm and semen parameters on this occasion only. I consent to the performance of semen analysis testing and understand that (a) the resulting report will be given to the referring clinician only (b) the results and their implications will be communicated to me by the referring clinician or other medical professional only and (c) the sample will be disposed of immediately after testing.

Print: …………………………… Sign: …………………………….. Date: ………………………….