[p.1 of Form (7)]
Consent Form (7) (Revised in 2012)
SAMPLE
Consent to In Vitro Fertilization/Embryo Transfer
To be used for every treatment cycle involving
(i) fresh embryo transfer; or (ii) the use of donor gametes/embryos
(whether such embryos are transferred in a fresh or frozen-thawed state)
PART I
PATIENT’S CONSENT
1.
I _________________________________________________________________, of
(Surname, Given Names)
(ID No.)
______________________________________________________________(address),
being lawfully married and desirous of having a child, DO HEREBY AUTHORISE
__________________________________________ (name of reproductive technology
centre) (hereinafter called “the Centre”), to perform the treatment of in-vitro
fertilization/embryo transfer for me.
2.
I also hereby consent that the Centre may proceed with the following reproductive
technology procedures for me (please tick as appropriate) ( )
( )
( )
3.
in vitro fertilization & embryo transfer;
pronuclear stage tubal transfer;
others (please specify)______________________________________ .
I consent to (a)
(b)
(c)
(d)
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 appropriate drugs and/or anaesthetics to me if necessary
for the said procedure(s); and
the transfer of gametes/embryos to my body .
4.Note I consent to the mixing of the gametes of _________________________________ with
those of ________________________________________________________. (please
specify the reference no. of man who provides the sperm and woman who provides the eggs (oocytes))
5.
I understand that the donor(s) of the gamete(s)/embryo(s) shall remain anonymous*
(please delete this sentence if the donation is designated). Under the Parent & Child Ordinance
(Cap. 429), the donor(s) shall not be the legal parent(s) of any child(ren) born from the
aforesaid treatment procedure.* (please delete the entire paragraph if no donated
gamete(s)/embryo(s) are involved)
6.
I acknowledge that the nature, procedures and possible complications of the treatment
procedure have been explained to me by ____________________________________
Consent Form (7) (Revised in 2012)
[p.2 of Form (7)]
and I have been given the opportunity to ask any question I wish. I have also been
offered a suitable opportunity to take part in counselling with
______________________________about the implications of the treatment procedure.
7.
I fully understand and accept that (a) the aforesaid treatment procedures may not result in a successful pregnancy;
(b) I may not be able to carry the pregnancy to term;
(c) I may suffer from illness(es) or complications arising out of or consequent upon a
pregnancy resulting from in-vitro fertilization/embryo transfer; and
(d) any child conceived or born 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 understand that the procedures as listed in para. 2 will not be performed if my
husband revokes or varies his consent before the transfer of gamete(s) or embryo(s) to
me.
9.
I consent that unfertilised eggs (oocytes) obtained from me and/or excess embryos
produced in the course of the procedures listed in para. 2 above may be (please tick one)
-
10.
[
]
disposed of in accordance with the “Guidelines on disposal of gametes or
embryos” (“the Guidelines”) in the Code of Practice on Reproductive
Technology and Embryo Research published from time to time by the Council
on Human Reproductive Technology.
[
]
donated anonymously for the treatment of other infertile couples, in which
event my gametes or embryos would not be used to produce more than a total
of 1/2/3* live birth events (failing which the Centre may dispose of the stored
gametes or embryos in accordance with the Guidelines).
[
]
donated for research (failing which the Centre may dispose of the stored
gametes or embryos in accordance with the Guidelines).
[
]
donated for quality control and/or training (failing which the Centre may
dispose of the stored gametes or embryos in accordance with the Guidelines).
I acknowledge that the Information Sheet(s) at Appendix X* (delete this appendix for
cases not involving use of donor gametes/embryos) and/or Appendix XI of the Code of
Practice on Reproductive Technology and Embryo Research has/have been read by
me/explained to me*. I fully understand the contents of the Information Sheet(s) and I
agree that my personal data and information may be used for the purposes as set out
therein.
Consent Form (7) (Revised in 2012)
[p.3 of Form (7)]
Dated the
day of
(Month)
(Year)
Signed
(Patient’s Signature)
Name
(in Block Letters)
Signed
(in Chinese)
Signed
(Signature of Attending Doctor)
Name
(Signature of Witness)
Name
(in Block Letters)
(in Block Letters)
Position
Consent Form (7) (Revised in 2012)
[p.4 of Form (7)]
PART II
HUSBAND’S CONSENT
11.
I _________________________________________________________________ am
(Surname, Given Names)
(ID No.)
the husband of _________________________________________ and I consent to the
course of treatment outlined above. I understand that I will be the legal father of any
child(ren) born from the treatment.
12.
I understand that this consent cannot be revoked or varied once the gamete(s) or
embryo(s) has/have been transferred to my wife. Any revocation or variation of this
consent will not be effective until actual receipt by the Centre in writing.
13.
I consent that excess embryos produced in the course of the procedures listed in the
para. 2 above may be handled in accordance with my wife’s instructions, as set out in
para. 9 hereof.
14.
I acknowledge that the Information Sheet(s) at Appendix X* (delete this appendix for
cases not involving use of donor gametes/embryos) and/or Appendix XI of the Code of
Practice on Reproductive Technology and Embryo Research has/have been read by
me/explained to me*. I fully understand the contents of the Information Sheet(s) and I
agree that my personal data and information may be used for the purposes as set out
therein.
Dated the
day of
(Month)
(Year)
Signed
(Husband’s Signature)
Name
(in Block Letters)
(in Chinese)
Marriage Certificate No.
*
Delete whichever is inapplicable.
Note:
Under normal circumstances, gametes from the husband and wife should be used.
The use of donated gamete(s) would be subject to proof of difficulties in obtaining
normal gametes from either the husband or the wife.
Consent Form (7) (Revised in 2012)