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