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PREGNANCY REPORT FORM

The California State Department of Health requires that all semen banks maintain documentation of pregnancies resulting from donor insemination. These guidelines have certain geographical boundaries. To keep our records updated, it is important that you inform us about each successful clinical pregnancy as soon as possible. Your cooperation is greatly appreciated. Please provide the following information for each clinical pregnancy (ongoing pregnancy and pregnancy resulting in a miscarriage). Patient Name: Address Telephone: Email:

City, State & Zip Code

Patient Sex

___Male

___Female

#Insemination per cycle: Physician Name: Insemination Date:

#Cycles:

Donor ID#: Telephone:

Vial Code:

Vial Date:

Method: ___ ICI ___Other Explain:

___IUI ___ART

Reason for donor sperm insemination: ___Male infertility ___Single woman ___Genetic disease ___Other. Please specify:

Explain:

Were fertility drugs used? ____Yes ____No Expected delivery date:

If yes, what drugs?

Comments:

Name of person preparing the form:

Signature: ________________________________

Date:

Submit Form

6699 ALVARADO ROAD #2208 SAN DIEGO, CA 92120 TEL 619.265.0102 · FAX 619.265.1429

Print Form

12751 NEWPORT AVENUE #206 TUSTIN, CA 92780 TEL 714.730.3060 · FAX 714.730.3063

www.spermbankcalifornia.com [email protected]

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