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Pregnancy Report Form
To be completed by all successful clients using our donor sperm, and is required as part of our client agreement when purchasing donor specimens.
This information is used for verification and statistical purposes by the Cryobank only.
Name (full name of account with us):
 
Please provide your complete email address
 @
   
What donor did you use to create the pregnancy?
   
Is this report being filed as follow up information to a
pregnancy already reported?
No     Yes
How many cycles did you complete AI prior to success?
 1     2     3     4
5     6 or more
Where were the inseminations completed?

Home     Doctors Office

   
If the pregnancy was achieved through home insemination, did you use
 Cup   Syringe/Catheter Both
   
How many vials did you use on each cycle?
 1    2    3   more, per cycle
   
How did you time the insemination/s past the LH surge?
 12 hrs     24 hrs     36 hrs     
48 hrs     more other
What is your age?
Do you have any known fertility problems?
Would you be willing to act as a reference to others seeking this service?
 No     Yes by email
Yes by phone
If yes please provide email or phone number.
Follow up information/Other comments such as:
-full term healthy birth
-son or daughter born
-problems with pregnancy or miscarriage, how far along

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