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Frozen Embryo Thaw; Transfer Consent


I, ____________________ (the Patient), and my partner, _______________________ (the Partner), being single/married/unmarried (please circle), approve and consent to allow my/our cryopreserved embryos to be thawed by Preserving Your egacy, Inc!, its sta"" and physicians (collectively, the Preserving Your egacy, Inc!), and i" viable, trans"erred in an attempt to achieve a pregnancy (the Procedure)! #! $escription o" Procedure! I/%e understand that one, some, or all o" my/our embryos will be thawed according to Preserving Your egacy, Inc! protocols and the discretion o" the laboratory and or doctor! &hese embryos will be prepared in the laboratory "or a 'ro(en )mbryo &rans"er (')&)! *s part o" the Procedure these embryos will undergo *ssisted +atched (*+) which is a microtechni,ue that is per"ormed on the embryos to "acilitate their hatching "rom the (ona "or implantation! -! .is/s/*lternatives! &he Procedure has been e0plained to me/us and I/we have been provided with the necessary in"ormation to evaluate the ris/s, bene"its, and possible ris/s, side e""ects and complications o" the proposed Procedure! I/%e have also received in"ormation regarding (a) the purpose o" the Procedure1 (b) alternatives to the Procedure as well as the relevant ris/s and bene"its o" such alternative treatment1 (c) clinical outcomes i" I/we do not elect to have the proposed Procedure1 and (e) the li/elihood o" achieving care, treatment and service goals! 2peci"ically, I/%e understand that3 a! there is no guarantee that the embryos will survive the "ree(ing, thawing or the assisted hatching process, and that rare e,uipment "ailures or laboratory accidents can occur, any o" which may cancel the trans"er o" my/our embryos! b! there is no guarantee that a pregnancy will occur i" or when my/our embryos are trans"erred bac/ to the uterus! c! i" pregnancy occurs, there are other ris/s, including, but not limited to, ectopic pregnancy, miscarriage, multiple birth, stillbirth and or congenital abnormalities (birth de"ects)! d! the rate o" congenital abnormalities (birth de"ects) in babies conceived naturally is -456 and is not /nown to be di""erent in babies conceived with I7' or ')&! 5! 8o 9uarantees! I/%e have been in"ormed that there are other ris/s, complications and conse,uences that are attendant to the per"ormance o" any Procedure, which have been e0plained to me/us! I/%e ac/nowledge that no guarantees or assurances have been made to me/us concerning the results o" the above Procedure! I/%e understand and ac/nowledge that medicine is not an e0act science and that in cases o" doubt Preserving Your egacy, Inc! will e0ercise its pro"essional :udgment! I/%e "urther

ac/nowledge that as I/we proceed changes may occur in my/our treatment plan and I/we may be as/ed to sign additional consent "orms! ;! .elease/Indemni"ication! I/%e agree that Preserving Your egacy, Inc! shall not be held liable "or any actions, e0penses, or damages relating to the collection, "ree(ing, storage, release, loss, damage, or destruction o" the embryo(s)! I/we agree to indemni"y, de"end and hold harmless Preserving Your egacy, Inc! "rom and against any loss or damage sustained by Preserving Your egacy, Inc! as a result o" (a) the procedure provided the loss or damage does not result "rom Preserving Your egacy, Inc! negligence or pro"essional misconduct1 and (b) the legal status o" any o""spring or the e0istence or non4e0istence o" parental rights or obligations with respect to you or any other person whatsoever! &his release and indemni"ication shall survive termination o" this consent "or any reason whatsoever! <! =on"identiality! I understand that any in"ormation that is obtained in connection with my treatment and that can be used to identi"y me will remain con"idential! >y name and address will remain on "ile at the tissue ban/, and shall not be disclosed to any person or entity, e0cept upon my written in"ormed consent, or to authori(ed employees o" Preserving Your egacy, Inc! or as permitted by law! In addition, data "rom all I7' procedure will also be provided to the =enters "or $isease =ontrol and Prevention (the =$=)! &he #??- 'ertility =linic 2uccess .ate and =erti"ication *ct re,uires that =$= collect data on all assisted reproductive technology cycles per"ormed in the @nited 2tates annually and report success rates using this data! Aecause sensitive in"ormation is collected, the =$= applied "or and received an assurance o" con"identiality "or this pro:ect under the provisions o" the Public +ealth 2ervice *ct, 2ection 5BC (d)! &his means that any in"ormation that =$= has that identi"ies a gestational carrier will not be disclosed to anyone else without consent! *dditional in"ormation regarding how Preserving Your egacy, Inc! may use patient in"ormation is included in the Preserving Your egacy, Inc! Privacy 8otice! I/%e the undersigned have had the opportunity to have all o" my/our ,uestions about the Procedure answered to my/our satis"action! I/%e also understand the purpose, bene"its and ris/s involved in the Procedure! @nless treatment decisions change, this signed consent "orm will be considered valid "or one year! I" there are changes to these treatment decisions, a new consent "orm must be signed! INTENDING TO BE LEGALLY BOUND, the art!es hereto ha"e #a$se% th!s A&reement to be e'e#$te% as of the %ate f!rst abo"e wr!tten( AY_______________________ (Party #) _______________________ (8ame/Please Print) ______________________ ($ate) AY_______________________ (Party -) _______________________ (8ame/Please Print) ______________________ ($ate) AY_______________________ (Preserving Your egacy, Inc!)

_______________________ (8ame/Please Print) ______________________ ($ate)