EVMS Cryopreserved (Frozen) Reproductive Cells and Tissues (CRCT) Request Form: Do I have frozen samples remaining in storage at EVMS-JI?

EVMS Jones Institute (EVMS-JI) has closed its IVF Program and discontinued (ended) its Cryopreservation (Cryo) Program.

The sperm, eggs, embryos and reproductive tissues that remain in storage are safeguarded and monitored. However, according to the terms of EVMS-JI consent forms signed by patients, EVMS-JI intends to discard all sperm, eggs, embryos, and reproductive tissues that remain in storage on 12/1/2022. It is your responsibility to tell us what you want done with any samples you believe are in storage; and you may be required to pay storage fees until you decide. We are committed to working with you to accomplish your goals. In order to implement your wishes and discontinue your storage billing, we must receive your completed paperwork (including all consents and supporting documents) by September 1, 2022.

Please complete the information below for your own samples. For Oocytes (Eggs) and Sperm, only one person’s information is needed (the person who provided the specimens). For embryos, information for both partners is required unless donor sperm was used. In order to give you an accurate record of what is in storage, particularly if your partner has a different last name than you, it is always best to provide as much information as possible. Please be sure to use the names you used when a patient at EVMS-JI.

If you have any questions or concerns, please contact us at cryo@evms.edu or 757-446-8944.

Thank you!

Date

M-D-Y

Last Name

* must provide value

First Name

* must provide value

Middle Initial

Date of Birth

* must provide value

M-D-Y

Social Security Number

Address Line 1

Address Line 2

City

State

Zip Code

Daytime Phone

* must provide value

Email Address

*EVMS prefers to use email communication for this purpose

* must provide value

What type of frozen samples do you believe you have in storage with us?

Eggs

Embryos

Sperm (your own sperm)

Donor Sperm

Other

If other, what type of frozen samples do you believe that you have here?

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For embryos in storage, please check N/A if donor sperm from a sperm bank was used to create your embryos

N/A

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Partner Last Name

Partner First Name

Partner Date of Birth

Partner Daytime Phone Number

Partner Email

*EVMS prefers to use email communication for this purpose.

Partner Address Line 1 (if different from yours)

Partner City (if different from yours)

Partner State (if different from yours)

Partner Zip Code (if different from yours)

Please add any additional comments or information here

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By completing and submitting this form, I (we) authorize EVMS to release information regarding any Cryopreserved Specimens (CRCT or frozen samples) to the email addresses or physical addresses listed above. I/We understand that EVMS prefers email communication for this process and I/we take responsibility for all delays and missed deadlines which may occur if I/we do not provide an email address.

Patient Accepts

Partner Accepts

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