Delight Fertility Clinic
ดีไลท์ เฟอร์ทิลิตี้ คลินิกเฉพาะทางด้านเวชกรรมสูตินรีเวช
3388/63 อาคารสิรินรัตน์ ชั้น 18 ถนนพระรามที่ 4 เเขวงคลองตัน
เขตคลองเตย กรุงเทพมหานคร 10110
โทร. 02-0037372
Name :  Mrs.RONG CHENG     CN :  DF2500169-F
 

Consent Form Frozen-Embryo-Transfer (FET)

Explanation:

             Frozen-embryo transfer is the process cryopreservation of the fertilized ova for subsequent embryo transfer at the later time. Cryopreservation of the embryo will be implied whenever the number of embryos is exceeding the optimum for the singer uterine transfer, the cryo-preserved embryos will properly used for subsequent hormonal-primed cycle or subsequent pregnancy.
             For utilization of the frozen embryos, the embryo will properly be thawed to optimal conditions and properly verified before transferring into uterus. It has scientifically been know that cryopreservation the embryo not has no significant disadvantage but also causes less expenses for further ovarian stimulation and invitro fertilization. The efficacy of the FET is about is about 20-30 percent.
             Husband and wife have co-authorities upon the embryos. It is therefore, their own decision in the utilization unless there is other legal designation. I have gone through the instruction/explanation thoroughly discuss abut the FET and agreed for FET. I hereby deserve the right to withdraw at anytime from the FET without any effect to my future health care and management.
My spouse and I do accept the FET by the assistance of Dr
             In case of having no embryo development or having abnormal growth of the embryo under the appropriately technical assisting. My spouse and I deserve the right not to claim neither medical fault nor liability.
             My spouse and I have also under stood the the baby born following the FET take the same risks of congenital anomalies as those occurring in normal reproductive offspring.
             My spouse and I do accept FET. It is our own decision under the contemporary and future regulation. We do accept for the utilization of our embryos by the following conditions:
 
1. If the husband expired: The Decision of utilization of the frozen-embryo would belong to authority of:
             ( ) my wife     ( ) responsible hospital / Institute
2. If the wife expired: The Decision of utilization of the frozen-embryo would belong to authority of:
             ( ) my wife     ( ) responsible hospital / Institute
3. If the couple expired: I desire that the management of the frozen-embryo be
             ( ) disposal     ( ) valid management of the responsible hospital/Institute
 
 
Delight Fertility Clinic
ดีไลท์ เฟอร์ทิลิตี้ คลินิกเฉพาะทางด้านเวชกรรมสูตินรีเวช
3388/63 อาคารสิรินรัตน์ ชั้น 18 ถนนพระรามที่ 4 เเขวงคลองตัน
เขตคลองเตย กรุงเทพมหานคร 10110
โทร. 02-0037372
Name :  Mrs.RONG CHENG     CN :  DF2500169-F
 
4. If the divorce: I desire that the management of the frozen-embryo be
             ( ) disposal
             ( ) valid management of the responsible hospital/Institute
             ( ) husband’s authority
             ( ) wife’s authority
             ( ) others ( Specify )
             5. My Spouse and I need no responsibility to decide upon our embryos if missing contact with the hospital institute longer than 1 year or unable to compensate for the preservation of the embryos. I do accept utilization of the frozen embryos for medical research or disposal under the Thai Medical Council regulation.
 
 
  Signature Woman   Signature Husband
  ( )   ( )
 
  Signature Witness   Signature Witness
  ( )   ( )
  Signature Doctor/ Educator   Date  
  ( )