提出先：培養室継続更新 胚凍結

EL-R037③_2024.06.17

Continuous Updates
Consent form for Embryo Cryopreservation
Fertility Clinic Tokyo
Dr. Yasushi Odawara

Date of explanation

cryopreserved embryo record//

Embryologist

frozen day/

/

（No,）

frozen day/

/

（No,）

frozen day//（No,）

frozen day

/

/

（No,）

Expiration of storage//

Please check the box and fill in the following items
Consent Items□We had an explanation about the methods and risks of cryopreservation.
□We agree that the couple must keep marital relationship and the age of wife must not exceed 50 years old when thepatient is used for treatment.

□We agree to indemnify and hold your clinic harmless in the event of any unforeseen circumstances, such as natural
disaster, fire, accident, etc., that interfere with storage at your clinic.

□We come to the clinic and renew the consent form within 3 months after the expiration date if we wish to renew it.
(The period of cryopreservation is one year starting from the date of freezing. If the renewal is covered byinsurance, the renewal can be made from the day after the storage expiration date.)□If we send this consent form by post, we agree to hold your clinic harmless from any liability in connection withthe mailing.
Consent for discarding embryo□We agree to dispose of the frozen embryos if there is no renewal procedure within 3 months of the retention period.
□We agree to dispose of the frozen embryos in case as follows.


Elimination of marital relationshipWife reaches 50 years old
Situations deemed difficult to treat□Email notification is required before expiration. ( Yes ・ No )The e-mail is an auxiliary means, so please manage the expiration by yourself.
If you change your e-mail address, please change your registration by yourself.

□In the event of the death of any of the spouses, freezing will not be continued no medical treatment will be performed
using the frozen embryos and embryo will not be used for any reproductive treatment.
We agree on the above and to provide treatment
The date signed//

ID No,

Wife Name（self written）
Husband Name（self written）
Address
TEL
Personal information in this consent form will be strictly controlled by Fertility Clinic Tokyo and will not be leaked to theoutside in any case. The consent form can be canceled any time before the start of treatment.

EL-R037④_2024.06.17

継続更新 胚凍結

Continuation and Renewal Embryo Cryopreservation
Consent Explanation Form
Please read and understand each item on the consent form, check each box below from the dotted line with a"□" mark, and fill in the required information.
If you have any questions, please ask the embryologist when you come to the clinic.
Cryopreservation Agreement
・There is about 2～3% risk of damaging embryo by thawing. In some cases, this may result in cancellation of thetransfer.

・The wife's age must be under 50 years old. Marital status must be continued.

・Although we take measures for natural disaster such as huge earthquake, flood, fire, or other accident, it may bedifficult to continue preservation.

・The cryopreservation period is one year. If you wish to renew your cryopreservation after that, please be sure tocome to the clinic within 3 months after the expiration date to complete a consent form for renewal. If therenewal is covered by insurance, the renewal can be made from the day after the storage expiration date.

・In principle, we do not accept this consent form by mail. However, if it is difficult to come to the clinic due tounavoidable circumstances, the patient is responsible for sending the form by certified or registered mail.
However, please note that the clinic assumes no responsibility for loss of the consent form due to postalaccidents.

Agreement on Disposal
・

If consent form is not renewal within 3 months after the expiration date, the frozen embryos will be automaticallydiscarded.

・In the event of divorce, if wife is over 50 years of age, or if it is medically determined that treatment is notfeasible, the frozen embryos will be discarded.

・We will notify you of the expiration date 40 days prior to the expiration date by e-mail.
Please circle "YES" if you wish to be notified, and "NO" if you do not wish to be notified.
If you want to contacted the clinic prior to the expiration date, please be sure to register your e-mail address withour clinic's web appointment system (@link). Please do not set your e-mail address to "Unsubscribe (do not needto subscribe)" as you will not be able to receive e-mails before the due date. The e-mail is an auxiliary means,so please manage the expiration by yourself. If you change your e-mail address, please change yourregistration by yourself.

・If one of the couple dies during the storage period, the frozen embryos will be discarded.

Please check the box again and bring the completed form to our clinic.
Fertility Clinic Tokyo