FORM 1 SpermComet™ Test Request Form
to be completed by referring clinic and emailed to
lab@lewisfertilitytesting.comReferring Clinician/GP/Healthcare
Professional
(if applicable)
Address
Sample Information
Date of sample collection
Abstinence time (days)
For LFT use
Ejaculate or Surgically Retrieved Sperm
Sperm Count
Semen Analysis
Normal / Abnormal
Patient Name
Address
Tel. Number
DOB and Age
Smoker (yes/no) Number/day
Medication
Dietary supplements
Occupation