IVF Patient Consent Form

IVF Patient Consent Form

Patient Information

Date of Birth:    Gender:

Home Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Medical & Reproductive History

Description of Procedure

I consent to undergo assisted reproductive procedures including ovarian stimulation, monitoring, oocyte retrieval, fertilization of oocytes by partner or donor sperm, incubation of embryos, embryo transfer, and cryopreservation of embryos or oocytes as indicated by the treating physician. Planned cycle start date:

Consent Items and Acknowledgements

I authorize stimulation medications and monitoring necessary for in vitro fertilization and related procedures, including appropriate ultrasounds and blood tests. I consent

I consent to oocyte retrieval under sedation or anesthesia, understanding the risks of anesthesia and the possibility of conversion to general anesthesia if indicated. I consent

I consent to fertilization by partner, donor, or by intracytoplasmic sperm injection (ICSI) if indicated. I understand that the laboratory will determine fertilization and that some oocytes may not fertilize. I consent

I consent to embryo transfer of up to the number of embryos recommended by my physician and acknowledge the increased risk of multiple pregnancy with multiple embryo transfer. I consent

Cryopreservation: I consent to cryopreservation of embryos or oocytes when medically indicated. I understand storage requires ongoing fees and that I will be asked to provide written disposition instructions for any embryos/oocytes remaining in storage. I consent

Genetic Testing: I consent to preimplantation genetic testing if recommended. I understand testing has limitations, may not detect all genetic abnormalities, and may result in no transferable embryos. I consent

Donor Gametes / Embryos: If donor sperm, eggs, or embryos are used, I acknowledge specific donor consent and screening procedures will apply and I accept the legal and ethical implications of using donor material. I consent

Blood Products: I consent to administration of blood products or blood testing if deemed medically necessary. I consent

Acknowledgement of Risks

I acknowledge that I have been informed of the reasonably foreseeable risks, which may include but are not limited to ovarian hyperstimulation syndrome, multiple pregnancy, ectopic pregnancy, bleeding, infection, anesthesia complications, emotional stress, cycle cancellation, failed fertilization, abnormal embryo development, and congenital anomalies. There are no guarantees of success. Initials:

Alternatives and Voluntary Decision

I understand alternatives may include no treatment, use of donor gametes or embryos, adoption, or alternative fertility treatments. I acknowledge that participation is voluntary and I may withdraw consent at any time prior to procedures without penalty; however, withdrawal may not be possible for actions already taken.

Disposition of Embryos / Storage Instructions

In the event embryos remain in storage, I direct the clinic as follows (select one or provide alternate written instruction):

Dispose of embryos in a manner consistent with clinic policy when I am no longer able to be contacted or upon my written request.

Donate embryos to another individual or couple for reproductive use.

Donate embryos to research consistent with applicable law and clinic policy.

Other instructions:

Financial Responsibility and Storage Fees

I understand services provided in connection with IVF are separate from insurance coverage and that I am financially responsible for all fees, including laboratory procedures and ongoing storage fees for cryopreserved material. Failure to pay applicable storage fees may result in disposition in accordance with clinic policy and any prior written instructions I have provided. I acknowledge financial responsibility

Privacy and Release of Medical Information

I acknowledge that I have received the clinic's privacy practices and that medical information related to my care may be used and disclosed for treatment, payment, and healthcare operations as permitted by law. I authorize release of my medical records and reproductive information to other treating providers and to insurance carriers as necessary for treatment and billing. I acknowledge

I authorize the clinic to use my de-identified clinical data for quality assurance, internal research, and education unless I specifically withhold such authorization by written notice. I consent

Authorization Expiration

This consent and any authorizations contained herein remain in effect until revoked in writing, except where specific instructions or time limits are stated below. Authorization expiration date (if desired):

Patient Certification

I certify that I have read and understand this consent form, that my questions have been answered to my satisfaction, and that I have had the opportunity to discuss the procedure, risks, benefits, and alternatives with my physician or other qualified staff. I acknowledge no guarantee has been made regarding the outcome of any treatment or procedure.

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