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Below are the forms that ReproTech requires your long-term storage patients to complete prior to cryopreservation for ReproTech account setup.
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.
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 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 CNA Financial Corporation, a premier insurance broker in the U.S.
Donor Tissue
- AE ACQ-100 Donor Tissue Cryostorage Agreement – Semen/Oocyte
- AES ACQ-100 Acuerdo Para La Criopreservacion De Tejido Donado
- D ACQ-100 Donor Tissue – Semen or Oocyte Registration
- DS ACQ-100 Registro – Tejido Donado Semen u Ovulo
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
- AUS ACQ-100 Autorizacion Para El Traslado De Muestras a RTL y Para La Entrega De Datos Medicos – Correo
Semen
- D ACQ-100 All Tissues – Registration
- DS ACQ-100 Registro – Embrion/Esperma/Oocitos/Tejido Testiculr u Ovarico
- N ACQ-100 Semen/Testicular Tissue Cryostorage Agreement
- NS ACQ-100 Acuerdo Para El Crioalmacenamiento De Semen/Tejido Testicular
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
- AUS ACQ-100 Autorizacion Para El Traslado De Muestras a RTL y Para La Entrega De Datos Medicos – Correo
Oocyte/Ovarian Tissue
- AA ACQ-100 Oocyte/Ovarian Tissue Cryostorage Agreement
- AAS ACQ-100 Acuerdo Para La Criopreservacion De Oocito/Tejido Ovarico
- D ACQ-100 All Tissues – Registration
- DS ACQ-100 Registro – Embrion/Esperma/Oocitos/Tejido Testiculr u Ovarico
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
- AUS ACQ-100 Autorizacion Para El Traslado De Muestras a RTL y Para La Entrega De Datos Medicos – Correo
Embryo
- D ACQ-100 All Tissues – Registration
- DS ACQ-100 Registro Embrion/Esperma/Oocitos/Tejido Testiculr u Ovarico
- O ACQ-100 Embryo Cryostorage Agreement – Client Depositor Couple
- OS ACQ-100 Acuerdo Para El Crioalmacenamiento De Embriones – Pareja De Clientes Depositantes
- ACS ACQ-100 Acuerdo Para El Crioalmacenamiento De Embriones – Embrión Cliente Depositante Solo
- AU ACQ-100 Specimen Transfer to RTL and Medical Data Release Authorization
- AUS ACQ-100 Autorizacion Para El Traslado De Muestras a RTL y Para La Entrega De Datos Medicos – Correo
All Tissues – Transfer FROM RTL
- AT DIS-100 Special Circumstance Release – Donor Tissue
- BJ DIS-100 Specimen Transfer from RTL and Medical Data Release Authorization – Embryo/Sperm/Oocytes/Testicular or Ovarian Tissue
- BJS DIS-100 Autorizacion Para El Traslado De Muestras Deside RTL y Para La Entrega De Datos Medicos – Embrion/Esperma/Oocitos/Tejido Testiculr u Ovarico
-
RS DIS-100 Documentation Para La Entrega En Circumstancia Especial (Embrion)
- S DIS-100 Special CircumstanceDocumentation (Semen)
- SS DIS-100 Documentation Para La Entrega En Circumstancia Especial (Semen)
- BC DIS-100 Special Circumstance Release – Oocyte/Ovarian Tissue