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 Insurance is available exclusively to ReproTech clients through Falvey Cargo Insurance Group, a premier insurance broker in the U.S.
Please note: a separate Addendum to Cryostorage Agreement for potentially infectious clients is no longer required for new accounts. We have incorporated this language into our new storage agreements as of 7/31/20.
Donor Tissue
- D ACQ-100 Registration – All Tissues
- AE ACQ-100 Donor Tissue Cryostorage Agreement – Semen or Oocyte
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
Semen/Testicular Tissue
- D ACQ-100 Registration – All Tissues
- N ACQ-100 Semen/Testicular Tissue Cryostorage Agreement
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
Oocyte/Ovarian Tissue
- D ACQ-100 Registration – All Tissues
- AA ACQ-100 Oocyte/Ovarian Tissue Cryostorage Agreement
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
Embryo
- D ACQ-100 Registration – All Tissues
- AC ACQ-100 Embryo Cryostorage Agreement – Single Client Depositor
- O ACQ-100 Embryo Cryostorage Agreement – Client Depositor Couple
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
All Tissues – Transfer FROM RTL
- BJ DIS-100 Specimen Transfer from RTL and Medical Data Release Authorization – Embryo/Sperm/Oocytes/Testicular or Ovarian Tissue
- BO DIS-100 Specimen Transfer from RTL and Medical Data Release Authorization – Research/Continued Storage/Therapeutic Use – Courier
- R DIS-100 Special Circumstance Release – Embryo
- BC DIS-100 Special Circumstance Release – Oocyte/Ovarian Tissue
- S DIS-100 Special Circumstance Release – Semen
- AT DIS-100 Special Circumstance Release – Donor Tissue
- AG DIS-100 Special Circumstance Release – Embryo/Gestational Carrier
- AD DIS-100 Informed Consent for Use of Embryos by Gestational Carrier
- BE DIS-100 Informed Consent for Use of Client Depositor Frozen Oocyte/Ovarian Tissue with Semen to Create Embryos for Transfer to Gestational Carrier
- AO DIS-100 Informed Consent for Use of Client Depositor Frozen Semen with Donor Eggs To Create Embryos For Transfer To Gestational Carrier
- AH DIS-100 Informed Consent for Use of Frozen Donor Tissue Specimens