3. Seattle Sperm Bank

Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address (Ex: 1234 Main St.)

Apartment, Suite, etc.

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Please upload a photo of your ID (front/back)*

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Please upload a photo of your insurance card (front/back) if you plan on using it to cover your visit with the physician.

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Before you finish this form, we wanted to share the exciting news. My Virtual Physician now has its own app. Available now on Android phones/tablets from the Google Play Store. Click here to download https://play.google.com/store/apps/details?id=com.lifehealthwalletusa.lifehealthwalletusa&hl=en&gl=US
Financial Agreement. An admin fee of $49.99 is required for our providers to initiate the request. You can use your insurance to cover the cost of the telehealth visit with the provider if the policy is participating with My Virtual Physician. If you opt to use self-pay, or your insurance is out of network, then an additional $24.99 fee will apply.

Seattle Sperm Bank*

Admin Fee

$49.99 Quantity

Total

$0.00

Reason for Submission*

I need a doctor to sign off on the release of fresh frozen spermI need a consultation regarding my fertility
Have you already purchased the Spermatozoa (sperm), and are you close to ovulation?*

YESNO
A virtual visit with our provider will be required to complete the request. By signing below I understand that I can use my insurance if in network for the telehealth visit. I understand that if my insurance is out of network, if I choose to not provide insurance information, or I am opting for self pay that an additional fee of 24.99 will apply.*

Clear
Disclosure

After completing this form a licensed provider will submit the request, and it is up to the patient to reach out to Seattle Sperm Bank for follow up.
Should be Empty:

Disclosure