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Vitalab Frozen Genetic Material Disposition Form

This is the place for you to indicate:

1) Who you are.

2) What you intend to freeze at Vitalab.

3) Your permission for Vitalab to store this material on your behalf.

4) The duration for which your permission is valid.

5) What happens in the event of your death or mental incapacity.

6) You understand your responsibilities.

7) Your signed declaration.

Background:

The stored sperm, eggs and/or embryos are frozen, through a process called vitrification.

This ensures a high survival rate when they are thawed for future use. It also ensures that while stored, the quality / potential is not affected by the passage of time, as would be associated with natural aging in the body.

While stored, the temperature is kept at -197°C using liquid nitrogen. The liquid nitrogen is produced on site at Vitalab, and the storage occurs in Dewars / Large Insulated Flasks. These are monitored continuously (24/7) with a combination of on-site and remote systems, ensuring safety.

The stored material remains your property, while Vitalab acts as a custodian, responsible for the safety and security. You are free to change your mind regarding how you wish to use, store or manage your stored sperm, eggs or embryos at any time.

This document communicates your wishes regarding your stored material, and does not constitute a financial contract, rather a position statement and consent, which can be withdrawn or altered at any time.

1) About You:

Enter Your Email Address For A Copy Of This Signed Form(Required)

Name:(Required)

Surname:(Required)

Date Of Birth(Required)

ID / Passport Number:(Required)

Current Date(Required)

Vitalab File Number:(Required)

Patient Signature (Required)

Full Name

Email Address

What you are storing:

Kindly indicate by ticking the appropriate box below, what you intend to give Vitalab permission to store:(Required)

Sperm

Eggs

Embryos

Ovarian Tissue

Testicular Tissue

Other

Please Specify(Required)

Patient Signature (Required)

Full Name

Email Address

Partner Signature

Full Name

Email Address

4) Permission for Vitalab to store the genetic material as indicated in (2) above:

I understand that by signing this document, I will be giving my permission for Vitalab to store my genetic material. This genetic material remains my property. The purpose of storing genetic material is to safeguard my future reproductive choices. I am free to discard, transfer, or use this genetic material in an assisted reproductive technique.

I understand that I can withdraw my permission for this storage at any time. I can also change my mind regarding the duration of my consent or the instructions for the handling of my stored genetic material in the event of death or disability.

5) How long do you consent to store your genetic material:

You can consent to store your genetic material (sperm, eggs or embryos) up to 10 years. The consent period will start from the date of storage of the sperm, eggs or embryos. This is your storage anniversary date.

Indicate your choice below:(Required)

For 10 years

For a specific period (up to a maximum of 10 years)

Specify the number of years(Required)

You can always change this time, by completing this form again, and specifying another duration. The second form would supersede the first form.
If you wish to store for longer than 10 years, you will need to fill a new form, prior to the expiration of the first 10-year period.
Previously the consent to store the sperm, eggs and embryos was for 1 year, which meant a new form needed to be filled every year. This is not necessary where permission has been granted for a longer period.
At any point in time, if you change your mind or your circumstances change, you are free to update your consent and instruction regarding the storage and use of your genetic material.

Patient Signature (Required)

Full Name

Email Address

Partner Signature

Full Name

Email Address

6) What happens if you die or become unable to make decisions for yourself:

You need to decide what should happen to your stored genetic material in the event of your death or mental incapacity. If you do not indicate how your stored sperm, eggs or embryos should be handled, then they will be allowed to perish.

There are several choices available to you, as to how your stored sperm, eggs or embryos can be managed in the event of death or mental incapacity:

You may choose to ensure your stored sperm, eggs or embryos are allowed to perish. This will ensure there is no burden of ongoing storage fees and no possibility for the use of your genetic material in your physical / mental absence.
You can donate your stored sperm, eggs or embryos for the purposes of training embryologists and andrologists at Vitalab. It is understood that such training would involve training junior embryologist and andrologists in various techniques (thawing, freezing, analysis, biopsy, micro-manipulation, injection). There would be no use of this donated genetic material outside of the training environment at Vitalab. There would be no use of genetic material for the purposes of cloning, implantation or generation of life. This genetic material would not be available for use by any third parties outside of the Vitalab training embryologists and andrologists and would not generate any income for Vitalab.
If you are in a committed relationship, you may decide that your partner should be able to use your frozen sperm, eggs or embryos. This would allow for continuation of the future you had planned together. Your partner would be able to use your sperm, eggs or embryos to generate offspring (children).

Indicate your choice below as to how your frozen sperm, eggs or embryos should be managed in the event of your death or mental incapacity:(Required)

Allow to Perish

Donated for Training Purposes

For the treatment of current Partner

Patient Signature (Required)

Full Name

Email Address

Partner Signature

Full Name

Email Address

8) Your Declaration:

[cite: 141]

I declare the following: [cite: 142]

I have been given information on the different options set out in this form and the opportunity to review this information and ask questions related to this information.
I understand that I can make changes to, or withdraw my consent at any time, until the sperm or eggs, or embryos created from them have been allowed to perish.

The frozen and stored sperm, eggs or embryos remain my property.
I am free to discard them, use them at Vitalab, or transfer them for use elsewhere.
I understand that Vitalab will store my sperm, eggs or embryos, and that the preservation and security of my stored genetic material will incur an annual storage fee.
If this storage fee is not paid, and Vitalab is unable to contact me, I understand that they will allow my stored sperm, eggs or embryos to perish.

I understand the contents of this document.
I declare that I am the person named in section (1) above, and that all the information given in this form is correct and complete.

Patient Signature (Required)

Full Name

Email Address

Partner Signature

Full Name

Email Address

Witness Signature (Required)

Full Name

Email Address

INTERPRETER ?(Required)

Yes

REQUIREMENTS FOR INTERPRETER:

Interpreter Declaration(Required)

If the services of an interpreter have been used, to assist the couple in understanding the content to the Vitalab Frozen Genetic Material Disposition Form it is essential for the interpreter to sign the following:

Interpreter Declaration:

I Declare that I have assisted with the interpretation of the Online Patient Information regarding Mosaic Embryo Transfer provided by Vitalab and the consent form.

I have provided this service in .

Declare that I have assisted the couple as identified in this form. To the best of my knowledge and ability as an interpreter, I have conveyed the content to the couple in a way that they are able to understand its meaning and am satisfied that any queries related to this form have been discussed to their satisfaction. They sign this form in full understanding of their rights and wishes for the future treatment of their stored genetic material.

Interpreter Signature (Required)

Full Name

Email Address

Consent on behalf of a Minor?(Required)

Yes

10) Consent on behalf of a Minor

Background:

Assistance by a parent or legal guardian is required if a child is under the age 12.
It is reasonable to seek the consent of a minor who has the capacity to grasp the nature and implications of the proposed treatment or procedure.
If there are two people with parental responsibility, one parent should not give consent concerning a major health decision of a child without giving due consideration to the views and wishes of the child and other parent.
The age at which a person can consent to medical treatment in South Africa is 12.
This is provided they have the maturity "to understand the benefits, risks, social and other implications of the treatment".
Children of this age may consent to medical treatment on their own behalf.
If the proposed treatment involves a surgical procedure, a sufficiently mature child may still consent, if he or she is "duly assisted by his or her parent or guardian".

If the person is a minor for whom the sperm, eggs or frozen tissue that is going to be frozen and stored:

Patient

First name(Required)

Surname(Required)

Date of birth

ID / Passport Number(Required)

Parent 1 (Required)

Full Name

Email Address

Parent 2

Full Name

Email Address

Embryo Disposition Consent Form

Vitalab Frozen Genetic Material Disposition Form

Background:

1) About You:

2) About Your Partner:

What you are storing:

4) Permission for Vitalab to store the genetic material as indicated in (2) above:

5) How long do you consent to store your genetic material:

6) What happens if you die or become unable to make decisions for yourself:

7) Your Responsibilities:

8) Your Declaration:

REQUIREMENTS FOR INTERPRETER:

10) Consent on behalf of a Minor

Background:

Patient

Gauteng

Kwa-Zulu Natal