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North Texas Male Infertility Center Sperm Lab

Laboratory Requisition

  Last name

  Mid name

  First name
Patient Phone #:*
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Time Collected: Time Received: 
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- SEMEN ANALYSIS (No appointment required)
Mon. - Thurs:
8:30 -11:00A.M. & 1:00 - 4:00P.M.
8:30A.M. - 1:00P.M.
- SPERM WASH Monday - Saturday (by appointment only)
- SPERM CRYOPRESERVATION Monday - Friday (by appointment only)

1.  Refrain from any sexual activity including masturbation for a minimum of 2-3 days.
2.  Before specimen collection, wash hands with soap, rinse well with water, and dry thoroughly. Collect the specimen by masturbation without the use of lubricants, creams, water, saliva, etc. during collection. Alternate methods may be discussed with your physician.
3.  Collect the specimen in a clean, dry plastic container provided by this lab or by your physician. Write your name on the lid and be sure it is secured for transport. Samples collected in plastic bags will not be accepted.
4.  Bring the specimen to the office within one hour of collection. Keep specimen between room temperature and body temperature (e.g. inside your shirt). If you are unable to deliver the specimen to the lab within one hour, a private room is available at the lab for the collection of the specimen.
5.  Full payment is collected at the time of service and may be made by check, cash, Discover, Visa, Pay-pall or MasterCard. NO INSURANCE IS ACCEPTED. An itemized statement that you may file with your insurance carrier will be provided. See disclaimer acknowledgment below.
6.  To obtain your results, contact the office of the physician that ordered the test. Laboratory personnel cannot discuss you results with you.

North Texas Male Infertility Center, P.A. maintains a high quality sperm testing specialty laboratory. It is the only specialty laboratory in the Dallas/Fort Worth metroplex certified by the Commission of Office Laboratory Accreditation and directed by a Fellowship-trained urologist/male infertility specialist.
Following ordered testing procedures, your sperm sample will be disposed of in the biohazard waste container maintained by the laboratory. Incineration of all bioharard waste in done of a contract with an independent medical waste services company..

* I have read the above and understand its content. I have been informed of the option to have this testing performed at the laboratory of my choice.

(Your digital signature (full name) is as legally binding as a physical signature.)