SpermComet - Lab Information

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FORM 1 SpermComet™ Test Request Form
to be completed by referring clinic and emailed to
Referring 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
Email
Tel. Number
DOB and Age
Smoker (yes/no) Number/day
Medication
Dietary supplements
Occupation