Medical Gonad Consent Form

MEDICAL GONAD CONSENT FORM

This Medical Gonad Consent Form documents the informed consent and contractual terms entered into by the undersigned Patient and the Provider for the evaluation, care, and specified gonadal medical procedure. Patient Name:

WHEREAS

WHEREAS Patient desires to undergo the procedure described in this agreement and has requested evaluation, counseling, and surgical or medical intervention relating to the gonads; and

WHEREAS Provider is duly qualified, licensed, and authorized to perform the procedures and deliver medical services necessary for the evaluation and treatment of the Patient, and Provider agrees to provide such services subject to the terms herein; and

WHEREAS the parties wish to set forth the scope, payment terms, confidentiality, and legal terms applicable to the provision of care and disposition of tissue and records.

SCOPE OF WORK / PROCEDURE DESCRIPTION

Procedure to be performed (select applicable and describe):

Gonadectomy (removal of gonads)    Gonadal biopsy    Gonadal tissue cryopreservation    Other (specify below)

RISKS, BENEFITS, AND ALTERNATIVES

Provider has explained to the Patient the nature and purpose of the proposed procedure, reasonable alternatives (including no treatment), and the reasonably foreseeable risks and complications, including but not limited to: infection, bleeding, wound complications, anesthesia-related risks, chronic pain, scarring, potential hormonal effects, thromboembolic events, allergic reactions, need for additional procedures, and the permanent loss of reproductive capability or gonadal endocrine function. Patient acknowledges an opportunity to discuss these matters and to have questions answered.

Patient acknowledges the specific reproductive and endocrine consequences of gonadal removal or destructive procedures and confirms whether fertility preservation has been discussed:

Fertility preservation discussed: Yes    No

SPECIMEN HANDLING AND PATHOLOGY

Tissue removed may be sent for pathological examination. Patient consents to diagnostic pathology and understands that tissue may be retained temporarily for diagnostic purposes and then disposed of per standard medical practice unless separate written arrangements for long-term storage or release are made.

Consent for research use of de-identified tissue: Yes    No

PAYMENT TERMS

Total Fee for Services: $

Deposit Required: $

Late Payment Fee:

TERM AND TERMINATION

This Agreement commences on the Start Date below and terminates upon completion of the described services or as otherwise provided herein. Start Date:    End Date:

Either party may terminate this Agreement for material breach or upon written notice. Notice period prior to elective termination:  days.

CONFIDENTIALITY

Patient medical records, communications, and information disclosed under this Agreement are Confidential Information. Provider will maintain confidentiality consistent with applicable law and professional obligations. Provider may disclose information as required by law, for treatment coordination, or with Patient's written authorization. The parties agree that confidentiality obligations survive termination of this Agreement.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state specified below. Governing State:

ENTIRE AGREEMENT

This document, together with any attachments and mutually executed consents, embodies the entire agreement between Patient and Provider concerning the services described and supersedes all prior discussions and agreements, whether oral or written. No amendment is effective unless in writing and signed by both parties.

PATIENT ACKNOWLEDGMENTS

I acknowledge that I have read and understand the information in this form, I have had all my questions answered to my satisfaction, and I voluntarily consent to the proposed procedure(s), anesthesia, and related care.

I understand the risks and consequences set forth in this form.
Alternatives, including no procedure, were discussed.
I had the opportunity to ask questions and they were answered.
I consent to this treatment voluntarily and without coercion.

ADDITIONAL INSTRUCTIONS / SPECIAL TERMS

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