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Report Your Insemination

Report Your Insemination

The California Cryobank (CCB) encourages all clients to complete the following Outcome of Insemination Report. The report should only be filled out when you have finished ordering specimens from CCB, so that you may report on the results of all vials at one time. This report provides information necessary to monitor the effectiveness of our specimens. When you complete this report, please be sure to press the submit button at the bottom of the page. All information is strictly confidential. If you have any questions about the Outcome of Insemination Report, please call 866-927-9622, ext. 7100 or ext. 1240.

Insemination Report Form

* Required Fields

Purchase Information * Account Number * Donor Number * Vial Number(s) (ie. 3442, 05.11.02 CCB-02)
If vial number is unknown please give the date the vials were shipped (mm/dd/yyyy)

Procedure Information * Date of Insemination (mm/dd/yyyy) How many cycles was the recipient inseminated or how many Assisted Reproductive Procedures were performed? How many inseminations per cycle? How many vials were used for each cycle or Assisted Reproductive Procedure?

Were fertility drugs used? Yes No If yes, which drug(s)?

If recipient had an IVF procedure, are embryos being stored? Yes No If yes, how many are in storage?

Recipient Year of Birth (yyyy)

This information is strictly confidential and will only be used in the case that we have a question regarding your insemination report.

Questions/ Comments:

California Cryobank thanks you for filling out this report.

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California Cryobank: Reproductive Tissue Services

Report Your Insemination

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