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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 Page 1 of 2 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 Page 2 of 2