Outreach Health Group Order Form

Outreach Health Group Order Form 2017-08-14T14:13:13+00:00
Patient Info

(As it appears on health card)

Patients Full Mailing Address
CMV Information

(if applicable)

For Calgary Regional Fertility Program patients only - REQUIRED

Fertility Information
Donor Information

(First Choice)

(Second Choice)

(Third Choice)

Sperm Bank Information

If booking a consultation, put N/A as number of units

Payment Information

** Payment MUST be received prior to shipment. **At this time we cannot accept Mastercard Debit Cards

Outreach Health Group Inc. - Terms and Conditions

PRIVACY AGREEMENT
In accordance with the Personal Health Information Act, I am consenting to allow Outreach Health Group Inc. to collect the following (but not limited to); (a) Current treatment cycle information. (b) Pregnancy and Live Birth Outcomes for statistical purposes. (c) Information from care provider regarding stored donor semen units. By returning this with your order, consent is given to Outreach Health Group Inc. to collect the preceding information as necessary. Any information collected is kept strictly confidential between Outreach Health Group Inc. and your care provider*

QUALITY COMMITMENT POLICIES

Xytex - Quality Commitment is in effect for 120 days after the shipping of units. Reports of quality must be submitted within 30 days of thaw. A copy of a negative Bhcg report is required by Xytex to review a quality report and determine if a unit is eligible for re-reimbursement

Units held in reserve at OHS are eligible for a 50% refund within 1 year of purchase, minus any owing storage. (Effective August 10, 2010)

Units purchased from the Special Access Listing (DSSAP), Limited Edition Listing or units that are for "Second Pregnancies Only" are not eligible for a refund. Units purchased as "Informed Consent", "Exceptional Release" or "XYGene Carrier" donors that need signed consents are not eligible for refunds.(Effective August 10, 2010)

Units that have been shipped are the property of the person named as the patient and are non-refundable.

IMPORTANT NOTE ABOUT MULTIPLE UNIT ORDERS

Discounts for orders of 6 or more units are applied when all units are ordered at the same time and is not retroactive to previously purchased units. The total number of units to purchase must be on the original order form to qualify. **Orders of 6 units or more are eligible for 1 year FREE Storage.

Outreach Health Group Accepts Visa, MasterCard, Certified Cheque, Money Order and Email Money Transfer. Payment MUST be received prior to shipment.

RESERVATION AND STORAGE POLICIES

Units placed in "reserve" are purchased by the client and held at Outreach Health Group until required. At the time of shipping a retrieval fee of $25.00 + hst will be applied as well as shipping costs and any owing storage. Storage - First month free. $25.00 + hst per month thereafter Storage - $250.00 + hst annually Storage fees are due on an annual basis. Storage fees will be automatically charged to the credit card on file. If no credit card is on file, you will be invoiced directly for the amount owing. Unpaid Accounts - 3 notification attempts will be made to notify you of the amount outstanding, if the account remains unpaid after the 3 notifications and 3 months, the units will revert back to the ownership of Outreach Health Group.

**By submitting this order form, I acknowledge that I have read and understand all the applicable fees listed on the Outreach Health Services Inc. website.

Payment MUST be received prior to shipment.

Please feel free to call with any questions or concerns regarding this document 1-866-785-4709

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