Fertility Treatment Consent Form

Personal Information

Full Name: Date of Birth: Partner's Name (if applicable):

Treatment Information

Type of Fertility Treatment: Treating Physician/Clinic:

Consent & Acknowledgements

I confirm that I have discussed the procedure, risks, and alternatives with my physician. I understand that participation is voluntary and I may withdraw consent at any time. I acknowledge that my medical information will be kept confidential. I understand that success is not guaranteed.

Additional Information/Questions

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Signature: Date: