Download ne-use-sperm-from-hep-c-partner - New England Fertility Institute

Female Patient Name:
Social Security #:
Male Patient Name:
Social Security #:
New England Fertility Institute
1275 Summer Street • Suite 201 • Stamford, CT 06905 • Tel: (203) 325-3200 • Fax: (203) 323-3130
Consent to Use Sperm From A
Hepatitis C Virus (HCV) Positive Partner
I/we, the undersigned, acknowledge my/our desire and intent to obtain assisted reproductive
technology services using sperm from my partner tested to be HCV positive. I/we also
acknowledge that I/we have had a full discussion of these services with my/our physician.
I/we understand that there are risks associated with treatment by artifical insemination using
sperm from an HCV positive partner and these risks have been explained to me/us by my/our
physician.
I/we acknowledge that I/we have had a full discussion of the use of sperm from an HCV
positive partner with an NEFI clinical staff and have been specifically advised that despite
reasonable precautions this may result in the birth of an abnormal child or children. One of the
abnormalities although rare, is the transmisson of HCV.
Although using Assisted Reproductive Technology procedures dose not involve intercourse, the
risk for transmitting HCV sexually is unknown.
I/we understand that infectious disease testing has been done prior to providing the sample and
proceeding to any treatment or artificial insemination or insemination of oocyte(s). However,
this does not totally eliminate the possibility of acquiring HCV.
I/we understand the potential psychological implications on the birth of the child or children
through the use of sperm from an HCV positive partner may have upon the relationship and the
child or children.
I/we realize these assisted reproductive technologies may not successfully result in pregnancy.
I/we further understand that if a pregnancy does occur, there are the possibilities of
complications of childbirth, stillbirth or miscarriage, the birth of an abnormal child/children, or of
other adverse consequences.
I/we also acknowledge our obligation to care for, support and otherwise treat in all respects as
a natural born child any child born as a result of sperm from an HCV positive partner used with
assisted reproductive technologies.
HCV-IC-0103
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I/we have reviewed all of these matters with my/our Physician(s), and my/our questions have
been answered. I/we believe the possibility of having a child through these services is a benefit,
which outweighs the possible adverse consequences which may occur. I acknowledge the
discussion, which took place regarding the information noted above and hereby authorize my
physician to perform the proposed treatment. I further authorize my physician; his/her
assistants, consultants, or designees to perform such procedures as are necessary, in the
exercise of his/her professional judgment, to remedy unforeseen acute conditions, which may
be revealed, during the course of the original treatment.
I acknowledge that medicine is not an exact science and that no guarantee or assurance has
been given by anyone as to the results that may be obtained by my consent to treatment.
New England Fertility Institute Has reviewed the information in detail, and I/we wish to
proceed.
Patient (Printed Name)
Signature of Patient
Date
Partner (Printed Name)
Signature of Partner
Date
Witness (Printed Name)
Signature of Witness
Date
HCV-IC-0103
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