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Semen Analysis Appointment Request
Please fill out the entire form and submit for an appointment request. PLEASE NOTE: (CRBI does NOT provide a translator or use translation services. Please schedule an appointment when you are able to bring a translator, or your appointment will be cancelled.)
Patient Name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date
Patient Phone Number
*
Please enter a valid phone number.
Can this phone number receive texts?
*
YES
NO
Patient Email
*
example@example.com
Partner's Name (If no partner, use patient name)
*
First Name
Last Name
Partner date of birth (If no partner, use patient date of birth)
*
-
Month
-
Day
Year
Date
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Are you a new or returning patient to CRBI?
*
NEW Patient
RETURNING Patient
Reason for appointment
*
CPT #89310 - Semen Analysis: count and motility
CPT #89320 Semen Analysis Complete: count, motility, & morphology
A doctors order is REQUIRED for a semen analysis appointment. Who is your referring M.D.?
*
Please provide the Doctor who referred you to CRBI
Please upload a copy of your doctor's order
Browse Files
Drag and drop files here
Choose a file
If unable to upload form, please bring a copy with you to your appointment (this is required).
Cancel
of
Appointment
*
Notes
Please provide any notes including requests for an earlier appointments if they become available.
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Note: WE DO NOT PARTICIPATE WITH ANY INSURANCE COMPANIES.
How do you plan on paying the $200 semen analysis fee?
*
Credit Card (all credit card payments must be made through our online portal prior to your appointment)
Cash (please provide exact amount on day of appointment)
Check (made out to CRBI on day of appointment)
Have you filled out and submitted a Patient Registration Form (either online or by hand) to our office?
*
YES
NO
Please provide a photocopy of your identification (If you are unable to upload at this time, please bring your ID to your appointment. This is required.)
Appointment Date
-
Month
-
Day
Year
Date
Appointment Time
Hour Minutes
AM
PM
AM/PM Option
Reminder Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: