Semen Analysis Consent Form

I authorize the practice(s) named above to communicate the results of my semen analysis to my partner

Partner Nmae

Her phone number is

I do NOT authorize the practice(s) named above to communicate the results of my semen analysis to my partner.

Please call me directly at

If you are unable to answer the call, we’d like to leave a message on your voicemail to facilitate the communication of your tests results (at the number indicated above). We are unable to do so without your authorization.

Yes, I authorize the practice(s) named above to leave confidential semen analysis results at the number listed above if the physicians or nurse practitioners are unable to reach me directly. I understand that I can call back with questions anytime.

No, I do not authorize the practice(s) named above to leave confidential semen analysis results on my voicemail.

Patient Name

Date of Birth

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Semen Analysis Consent Form

Adefris & Toppin Women’s Specialists

Associates in Women’s Health

Adefris & Toppin Women’s Specialists

Haugen OB/GYN

OBGYN Specialists

OBGYN & Infertility

6565 France Ave S Suite 300, Edina, MN 55435

Phone: 952-927-4045

Fax: 952-927-0867

Pay My Bill

Good Faith Estimate

Records Release to Diamond

Notice of Privacy Practices

Semen Analysis Consent Form

Adefris & Toppin Women’s Specialists

Associates in Women’s Health

Adefris & Toppin Women’s Specialists

Haugen OB/GYN

OBGYN Specialists

OBGYN & Infertility

6565 France Ave S Suite 300, Edina, MN 55435

Phone: 952-927-4045

Fax: 952-927-0867​

Pay My Bill

Good Faith Estimate

Records Release to Diamond

Notice of Privacy Practices

Fax: 952-927-0867