WPC %Ǥsyom4tǤsQb0᧋4XtoIT$;soe43EHQ|QRc LGʌP} F'QW !Bh"dE^HFGhxb3:* @N#teΤ|3Bs|o_$h\倝~8JA; {O8`JDm K7?8tGSRG0 'z)zfX =n} =g2~; 2[Rĝ%FYate8=R|ݻׯ?Yк?0 ה0g9)X:8.DD6V_ EDD-4x\\eE^j.)T/6)?2g8I,l4G:7d<¾>Ў*W[ &+'Z'my_5 z*H>,2O#lU N- %{ 0:^ w4 m 0c 1uj 72 0w 0 0 0 0f 0- 0 0D 1; 72 1 72TP05,,,,0(a Z6Times New Roman RegularX($USUS.,l. p-:i+003|xU(;3$2#  0  .3  0  3#37=CIQYag1.a.i.(1)(a)(i)1)a) i)(O;$0  2#  a  .3  0` (#(#(b$0  0` (#(#2#   .3  0 ` (#` (#(xir$0  0` (#(#0 ` (#` (#2#(  0  )3  0 (# (#($0  0` (#(#0 ` (#` (#0 (# (#2#(  a  )3  0h(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#2#(   )3  0h(#h(#($0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#2#  0  )3  0(#(#({$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#2#  a  )3  0p(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#2#     )3  0p(#p(#  xwCW[_cgkosCheck BoxCheck Box&&&&&&&&& xG#Iosw{Shadowed BoxShadowed Check Boxooooooooo !USUS.,  _ XijXX   OUTCOMEOFINSEMINATIONREPORT    ij____________________________________________________________________________________________________________  #ij#   PROCREATIVECRYOBANK,LLC   X;XijXX;3009N.BallasRd.Ste.352C  St.Louis,MO63131  Tel.(314)9973620FAX(314)8729040#X;X # x    &"5%XX;ONLYCOMPLETETHISFORMTOREPORTAPREGNANCY.  (8 %&"5AccountNumber:0  ____________________________________   % % PhysicianName:0  0 %%____________________________________` p  % % OrderNumberorLastShipmentDate:___________________________   DonorNumber:0  0 %%_____________________________________0% % %ProcessedDate:_______________p %%%% DateofInsemination:0  __________/_________/___________ % % HowmanycycleswastherecipientinseminatedorhowmanyARPswereperformed?______________________  Howmanyinseminationspercycle? _________________________________  HowmanyvialswereusedforeachcycleorARP?0  __________________________%% Methodofinsemination(pleasecircle): ( 0 e _IVI_0e%e%0 %%ICI0m  % %0 m %m %IUI0 % %0u%%_IVF_0u%u%GIFT0}%%_ZIFT_0}%}%0-%%Other________________-%-%   (wy3 Werefertilitydrugsused:0  0m  % %_____Yes0m %m %0u%%_____No(8u%u%  e  e Ifyes,whichdrug(s)?0 m __________________________________________________ m %m % RecipientYearofBirth0  _______________________________8H" % % Procedureresult: $ " 3"  0 e  3 2w&3  0e%e%  Recipientisnotpregnant. 3 ) ݌%%% Ќ  " 3"  0 e  3 2w&3  0e%e%  Recipientiscurrentlypregnant.0%%0u%%Expecteddeliverydate:0}u%u%__________/__________/___________ 3  ݌ '}%}% Ќ  ! !  (wyy " 3"  0 e  3 2w&3  0e%e%  Recipienthasapregnancyloss. 3 ݌! )%% Ќ  Natureofloss:0  0 %%0m  % %0 m %m %0 % % u #,"+%% ! !  (wyy " 3"   e  32w&3  0    Spontaneousabortion 31݌#",%% Ќ  " 3"   e  32w&3  0    Therapeuticabortion 3݌h%x$.%% Ќ  " 3"   e  32w&3  0    Other 3݌&&0%% Ќ   e   (wyy  e   Wasthefetusnormal?0 _________Yes u 0 % %__________Nox('2%%  e  e " 3"   32w&3  0    Recipientgavebirth.Numberofboy(s)_____________Numberofgirl(s)______________ 3݌*)4%% Ќ   e      *)5  e   Washealthstatusnormal? ________Yes u   __________No +*6 Reportby:___________________________________________________ % Date:________/________/________ -,9 OutcomeofInseminationReport08/01 6/F.; # # /.<  e