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.

City

Zip Code
State of residence
Date of Birth*

MonthDayYear
Date
Sex assigned at birth
Please upload a copy of your License or ID Verification*

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Do you plan on using insurance for your visit or our SELF PAY option? *
Please upload a photo of your insurance card (front/back) if you plan on using it to cover your visit with the physician.

Cancelof
If you select the Self-Pay option, would you be interested in completing a comprehensive medical intake form to potentially expedite the process and eliminate the requirement for a physician telehealth consultation for waiver fulfillment?
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
Financial Disclosure

A $49.99 admin fee will apply for every submission. The Dr. visit fee can be billed using insurance if we are participating with your insurance carrier.

Self Pay Patients or Out Of Network Insurance patients will pay an additional fee of $24.99 dollars to cover the cost of the visit making the total $74.98

If you have questions in regards to your Insurance Network Participation status or any other billing inquiry please contact the office by Text: 725 228 8277 Phone: 888 224 0804 or Email:Billing@myvirtualphysician.com
I have read and understand the Financial Disclosure*

Clear
Follow up 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.
Our office uses athenahealth, a secure and trusted electronic health record system that includes a convenient patient portal designed to help you stay connected to your care. Through the portal, you can easily access your medical records and test results, send secure messages to our office, request or manage appointments, complete forms ahead of your visit, participate in telehealth appointments when available, and view or pay bills. The patient portal gives you safe, 24/7 access to your health information and helps streamline communication with our care team from your computer or mobile device.

How to download the athenaPatient app:

• Apple App Store (iPhone/iPad):
https://apps.apple.com/us/app/athenapatient/id1644169294

• Google Play Store (Android):
https://play.google.com/store/apps/details?id=com.athenahealth.athenapatient

Once you are a registered patient in our system, you will receive an invitation to create your own username and password, which will be securely linked to the patient portal.

My Products*

Visit Fee

$49.99 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Follow up Disclosure