Fees & Forms

Physician Forms

Patient Forms 

The following forms require a witness for your signature:

Print a form and fill it out - do not sign it, yet!
If you DO appear in person at the Andrology Laboratory, you may have a UUHSC staff member "witness" your signature.
If you DO NOT appear in person at the Andrology Laboratory (e.g. you will be mailing in your request), have your signature notarized (you can do this at most banks).

Release of Medical Information

The University of Utah Health Science Center follows the Federal requirements for protection of your personal medical information. If you would like the University of Utah Health Sciences Center to share (or receive) your medical health information with anyone (spouse, family member, other health care provider, etc.) you must give written permission. Please use the Patient Authorization Disclosure or Receipt of Protected Health Information form to give permission. Please read and complete the entire form.

Please note: your signature must be witnessed by a UUHSC employee or a Notary Public.