Sample Collection Form
I acknowledge and agree that my sample will be analyzed by Vasectomy Verify LLC in a CLIA-registered lab. The test performed is a qualitative semen analysis intended for post-vasectomy evaluation. Certified laboratory personnel will examine the sample using 60 high-power fields under a 40x objective (total magnification: 400x). The comments provided are for informational purposes only to assist my physician and do not replace a full laboratory diagnostic. If needed, my physician may refer me for a quantitative semen analysis elsewhere. I understand that this report does not constitute medical advice and is not a substitute for consultation with a licensed healthcare provider. I also understand that this document contains private health information protected by state and federal law, and if received in error, I will contact 801‑725‑1042
(435) 888.8888