Healthcare Embryo Selection Form

HEALTHCARE EMBRYO SELECTION FORM

Clinic Name:    Patient Name:

Medical Record Number:    Date of Birth:    Gender:

Patient Information

Partner / Donor Information

Donor Type: Patient Partner Third-Party Donor

Embryo Identification and History

List embryos to be considered for selection. Complete all known identifiers. If additional embryos exist, attach a separate list that becomes part of this form.

Selection Criteria

Please indicate the primary basis for selecting embryo(s) for transfer or further handling. Multiple selections permitted; if conflicts arise, clinic staff will follow the most recent written instruction.

Select based on PGT reported euploid status
Select based on morphological grade (clinic grading)
Select based on time-lapse or morphokinetic analysis
Select specific Storage IDs listed above
Random selection among eligible embryos

Genetic Testing and Laboratory Options

I authorize or decline the following laboratory procedures as indicated. I understand that some procedures may affect embryo viability and that testing is subject to technical limitations.

PGT-A (Aneuploidy screening)
PGT-M (Monogenic/single-gene disorders) — specify condition:
PGT-SR (Structural rearrangement analysis)
Use morphological grading in selection
Permit re-biopsy of embryos if initial sample is inconclusive

Disposition Preferences

In the event an embryo is identified as abnormal, untransferable, or unsuitable, indicate your preferred disposition below. If multiple choices are selected, clinic will follow the first actionable instruction unless prohibited by law or policy.

Discard/destroy
Donate to research (if permitted by applicable law and facility policy)
Continue cryostorage until further instruction
Return to donor for separate disposition directions

Risks, Benefits, and Acknowledgments

I acknowledge that: (a) no selection or testing protocol guarantees a successful pregnancy or live birth; (b) embryo biopsy and genetic testing carry risks including but not limited to misdiagnosis, failed analysis, or damage to the embryo that may impair viability; (c) laboratory reports are subject to technical limitations and interpretation; (d) embryos may be misidentified despite careful safeguards, and the clinic will employ reasonable measures to prevent such errors.

I understand that I may withdraw this selection authorization prior to embryo warming or biopsy. Withdrawal after warming or after irreversible laboratory procedures may be impracticable and may result in the selection or discard proceeding. I agree to be financially responsible for costs associated with testing, storage, thawing, and transfer as described in clinic policy.

Confirmations: I have read and understand the risks and limitations described above. I accept financial responsibility for procedures and storage fees as applicable.

HIPAA Authorization and Release of Information

I authorize the clinic to disclose protected health information related to embryo testing, selection, and disposition to the following individual(s). This authorization is voluntary and may be revoked in writing except to the extent that action has already been taken in reliance on it.

HIPAA Authorization Expiration Date:

Certification and Consent

By signing below I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge. I authorize the clinic and associated laboratory personnel to perform the embryo selection, testing, disposition, and associated procedures indicated on this form. I release and hold harmless the clinic, its physicians, laboratory personnel, and agents from liability for actions taken in good faith in accordance with these directions, except in cases of gross negligence or willful misconduct.

Authorization Expiration

This embryo selection authorization will expire on:    If left blank, authorization remains in effect until revoked in writing or superseded by a later dated selection form.

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