Below are the forms that ReproTech requires your long-term storage patients to complete prior to cryopreservation for ReproTech account setup.
 
The “Transfer FROM RTL” forms at the bottom must be completed for patients’ tissues to be transferred back to your clinic. Please note that when returning specimens to your clinic, the Special Circumstance Release Documentation is also only required for those individuals who have either tested reactive for a communicable disease or are missing some of the required testing. The Specimen Transfer From RTL and Medical Information Release form will require patient signatures in the presence of a notary.
 
Specimen Shipping Liability Protection is available exclusively to ReproTech clients through CNA Financial Corporation, a premier insurance broker in the U.S.
 
Each time you access this webpage, please clear your browser cache to ensure you are viewing the most recent version of our forms. Learn how to clear your cache: https://its.uiowa.edu/support/article/719
 
Reproductive Tissue – Semen, Testicular Tissue, Oocytes, Ovarian Tissue – New Patients

• English:
  • SINGLE CD – Reproductive Tissue Forms Packet A02
  • COUPLE – Reproductive Tissue Forms Packet A17
  • MINOR – Reproductive Tissue Forms Packet A03
• Spanish:
  • SP-SINGLE CD – Reproductive Tissue Forms Packet – A02-S
  • SP-COUPLE – Reproductive Tissue Forms Packet A17-S
  • SP-MINOR – Reproductive Tissue Forms Packet A03-S

 
Embryo – New Patients

• English:
  • COUPLE – Embryo & Donor Embryo Forms Packet A16
  • SINGLE CD – Embryo & Donor Embryo Forms Packet A01
• Spanish:
  • SP-COUPLE – Embryo & Donor-Embryo Forms Packet A16-S
  • SP-SINGLE CD – Embryo & Donor-Embryo Forms Packet A01-S

 
All Tissues – Transfer FROM ReproTech – Returning to Clinic

• English:
  • Transfer FROM RTL Auth and Medical Data Release T01
  • Transfer FROM RTL Auth and Med Release – Research/Continued Storage/Therapeutic Use T02
  • Special Circumstance Release – Embryos T10
  • Special Circumstance Release – Oocyte Ov Tissue T06
  • Special Circumstance Release – Semen T11
  • Special Circumstance Release – Donor Embryos T09
  • Special Circumstance Release – Donor Tissue (semen & oocytes)T08
  • Special Circumstance Release – Embryo Gestational Carrier T07
• Spanish:
  • SP-Transfer from RTL Auth and Medical Data Release T01-S
  • SP-Special Circumstance Release Documentation – Embryos T10-S
  • SP-Special Circumstance Release Documentation-Semen T11-S

 
Lab Staff form

• Specimen Transfer Data – FILLABLE – DIS-050  Fillable version – This form is completed by lab staff, not patients