Oncofertility Programs and Testicular Tissue Cryopreservation Study

Welcome to all institutions who have implemented Ovarian Tissue and/or Testicular Tissue Cryopreservation Protocols. ReproTech requires your institution to complete and sign the following agreement to establish a relationship for shipping cryopreserved reproductive tissue for long-term storage to one of our four cryostorage centers (Florida, Minnesota, Nevada or Texas). Please contact Lea Wilcox, Fertility Preservation Network Manager, to prepare an agreement for your center; by emailing or calling 651-478-5611.

Below are the forms required by patients to set up a long-term storage account with ReproTech. Please have your patients/families complete the applicable forms before tissue retrieval and return to Jeanne Blank, jeblank@reprotech.com or via FAX to 651-489-0442. Please call Jeanne with questions about account set-up or forms at 651-489-0827.

Specimen Shipping Liability Protection is available exclusively to ReproTech clients through CNA Financial Corporation, a premier insurance broker in the U.S.

ReproTech offers its Verna’s Purse Financial Assistance Program for qualified patients.The eligibility criteria and application are included in the list of forms below. Please note that approval is not guaranteed, an application must be completed and submitted by each qualifying patient to ReproTech, who will advise if approved.

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 12/31/20.

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Oocyte/Ovarian Tissue

Patient Specimen Transfer Date – This form must be completed by lab staff, not patients

English Forms

Registration – English

Ovarian Tissue Cryostorage Agreement – Oncofertility – English

Specimen Transfer to RTL and Medical Data Release Authorization – English

Verna’s Purse Financial Assistance Application – Ovarian Tissue

Spanish Forms

Registration – Spanish

Ovarian Tissue Cryostorage Agreement – Oncofertility – Spanish

Specimen Transfer to RTL and Medical Data Release Authorization – Spanish

Testicular Tissue

Patient Specimen Transfer Date – This form must be completed by lab staff, not patients

English Forms

Registration – English

Testicular Tissue Cryostorage Agreement – TTC – English

Specimen Transfer to RTL and Medical Data Release Authorization – English

Verna’s Purse Financial Assistance Application – Testicular Tissue

Spanish Forms

Registration – Spanish

Testicualar Tissue Cryostorage Agreement – Oncofertility – Spanish

Specimen Transfer to RTL and Medical Data Release Authorization – Spanish