Vasectomy Test Request
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1Vasectomy Test Request
Patient Name:
Doctor:
Address:
Vasectomy Date:
Specimen Date:
Due Date:
Email Address:
Phone No.:
Cellphone No.:
Yes, you can leave a message on my machine
No, do not leave a message, email my results
Email Address:
First Test (after 6 weeks and 15 ejaculations)
Repeat Test
For Office Use Only
DT
P
/100HPF
R
F
T-1
PC
PC
HPF
T-2
LM
LM
T-3
EM
EM
MOTILE
T-4
PR
PR
Vasectomy Test Request
Patient Name:
Doctor:
Address:
Vasectomy Date:
Specimen Date:
Due Date:
Email Address:
Phone No.:
Cellphone No.:
Yes, you can leave a message on my machine
No, do not leave a message, email my results
Email Address:
First Test (after 6 weeks and 15 ejaculations)
Repeat Test
For Office Use Only
DT
P
/100HPF
R
F
T-1
PC
PC
HPF
T-2
LM
LM
T-3
EM
EM
MOTILE
T-4
PR
PR
Vasectomy Test Request
Patient Name:
Doctor:
Address:
Vasectomy Date:
Specimen Date:
Due Date:
Email Address:
Phone No.:
Cellphone No.:
Yes, you can leave a message on my machine
No, do not leave a message, email my results
Email Address:
First Test (after 6 weeks and 15 ejaculations)
Repeat Test
For Office Use Only
DT
P
/100HPF
R
F
T-1
PC
PC
HPF
T-2
LM
LM
T-3
EM
EM
MOTILE
T-4
PR
PR
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