ConsentForm (7)
Consent to In Vitro Fertilization/Gamete Intra-Fallopian Transfer/
Embrvo Transfer (includins frozenlthawed embryo) OVF/GIFT/ET)
PART I
l.
PATIENT'S CONSENT
of
I
(Surname,Given Names)
(ID No.)
(address),
being lawfully married and desirous of having a child, DO HEREBY AUTHORISE
(name of reproductivetechnology
centre) (hereinafter called "the Centre"), to perform the treatment of in-vitro
fertilization/ gameteintra-fallopi an transfer/embryotransfer for me.
2-
3.
I also hereby consent that the Centre may proceed with the following reproductive
technologyproceduresfor me (pleasetick as appropriate)( )
( )
( )
in vitro fertilization & embryo transfer;
gameteintra-fallopian transfer;
pronuclear stagetubal transfer;
( )
others(pleasespecify)
I consentto (a)
(b)
(c)
(d)
4.#
be prepared for egg (oocytes) retrieval including the use of drugs for
hyperstimulation;
the removal of eggs (oocytes) from my ovaries with the aid of
laparoscopy/ultrasound;
the administration of appropriatedrugs and/or anaestheticsto me if necessary
for the said procedwe(s); and
to mybody.
the transferof gametes/embryos
I consent to the mixing of the gametes of
with those of
(please speciff the reference no. of man who provides the sperm and woman who provides the eggs
(oocytes))
5.
*
I understandthat the donor(s) of the gamete(s)/embryo(0 shall remain anonymous
Under the Parent & Child Ordinance
is designatedl.
if thedonation
(please
deletethissentence
(Cap. 429), the donor(s) shall not be the legal parent(s)of any child(ren) born from the
aforesaid treatment procedure. * lplease delete the entire paragraph if no donated
gamete(s)/ embryo(s) are involved)
[p.2 of Form (7)]
6.
I acknowledgethat the nature, proceduresand possiblecomplicationsof the treatment
procedurehave been explained to me by
and I have been given the opportunity to ask any questionI wish. I have also been
counselling with
take part in
offered a suitable opportunity to
about the implicationsof the treatmentprocedure.
7.
I fully understandand acceptthat (a) the aforesaidtreatment proceduresmay not result in a successfulpregnancy;
(b) I may not be able to carry the pregnancyto term;
(c) I may suffer from illness(es)or complicationsarising out of or consequentupon a
fertilization/gamete intra-fallopian
pregnancy resulting
from
in-vitro
transfer/embryotransfer;
(d) any child conceived or bom as a result of the procedures,may suffer from defect(s)
of health or mental or physical impairment(s) as a result of congenital, hereditary
or other reasons,similar to the situation of a normal pregnancy.
8.
I understandthat the procedures as listed in paragraph2 will not be performed if my
husbandrevokes or varies his consentbefore the transfer of gamete(s)or embryo(s) to
me.
9.
I consent that unfertilised eggs (oocytes) obtained from me and"/orexcess embryos
produced in the course of the procedureslisted in paragraph2 above may be (please
tick one) t
]
disposed of in accordancewith the "Guidelines on disposal of gametes or
embryos" ("the Guidelines") in the Code of Practice published from time to
time by the Council on Human ReproductiveTechnology.
t
]
donated anon)rmouslyfor the treatment of other infertile couples, in which
event my gametesor embryoswould not be used to produce more than a total
of onel two/ three x live birth events(failing which the Centre may dispose of
the stored gametesor embryosin accordancewith the Guidelines).
I
]
donated for research (failing which the Centre may dispose of the stored
gametesor embryosin accordancewith the Guidelines).
[p.3 of Form (7)]
day of
Datedthe
(Month)
(Year)
Signed
(Patient'sSignature)
Name
(in Chinese)
(in Block Letters)
Signed
Signed
(Signatureof Witness)
(Signatureof Attending Doctor)
Name
Name
(in Block Letters)
(in Block Letters)
Position
[p.4of Form(7)]
HUSBAND'SCONSENT
PARTtr
10. I
(ID No.)
(Surname,Given Names)
and I consentto the
the husbandof
course of treatment outlined above. I understandthat I will be the legal father of any
child(ren) bom from the treatment.
I 1.
I understandthat this consent cannot be revoked or varied once the gamete(s)or
embryo(s) has/ have been transferredto my wife. Any revocation or variation of this
consentwill not be effective until actual receipt by the Centre in writing.
12.
I consentthat excessembryosproducedin the course of the procedureslisted in the
paragraph2 above may be handled in accordancewith my wife's instructions,as set out
in paragrapht hereof.
day of
Datedthe
(Month)
(Year)
Signed
(Husband's
Signature)
Name
(in Block Letters)
(in Chinese)
Marriage Certificate No.
Notes:
*
#
Delete whicheveris inapplicable.
Under normal circumstances,gametesfrom the husband and wife should be
used. The use of donatedgamete(s)would be subjectto proof of difficulties in
obtaining normal gametesfrom either the husbandor the wife.