FCLab Registration Form

Personal Information

First name * Middle name Last name * Date of birth * Gender

Contact Information

Street Address *

City *

State *

ZIP Code *

Email address * Confirm email address * Phone number Confirm phone number Emergency contact name Emergency contact phone Confirm emergency contact phone

Upload ID

Upload ID (PDF/JPG/PNG) *

I attest that the uploaded ID is valid, current, unaltered, and belongs to me or the person I am authorized to represent. I understand that providing false or unauthorized identification may result in service denial or further verification. *

Pickup Facility Information

Facility Facility ZIP Code

Reproductive Material Transfer

(The Client and Partner (if applicable) shall be referred to collectively as the "Client(s)") wish to transfer the following "Reproductive Material(s)" to FCLAB for continued storage:

Embryo *

Sperm or Testicular Tissue/Aspirate

Oocytes

Partner Information

Partner information is required when selecting Embryo as reproductive material.

Partner full name * Partner date of birth * Partner ID Upload (PDF/JPG/PNG) *

I attest that the uploaded ID is valid, current, unaltered, and belongs to me or the person I am authorized to represent. I understand that providing false or unauthorized identification may result in service denial or further verification. *

Guardian Information

Guardian information is required as the client is under 18 years of age.

Guardian full name * Guardian date of birth * Guardian ID Upload (PDF/JPG/PNG) *

12. DEATH OF CLIENT OR PARTNER OR DIVORCE

a) In the event of the death of the Client, I/we wish the Reproductive Material(s) to be: *

Please select one option for death of client.

i. Transferred to the sole responsibility for the Partner (if applicable), to do with as he/she wishes

Client initials:

Partner initials (if applicable):

ii. Donated to infertile couples

Client initials:

Partner initials (if applicable):

iii. Donated for medical research

Client initials:

Partner initials (if applicable):

iv. Discarded

Client initials:

Partner initials (if applicable):

b) In the event of the death of the Partner, we wish the Reproductive Material(s) to be: *

Please select one option for death of partner.

i. Transferred to the sole responsibility for the Client, to do with as he/she wishes

Client initials:

Partner initials (if applicable):

ii. Donated to infertile couples

Client initials:

Partner initials (if applicable):

iii. Donated for medical research

Client initials:

Partner initials (if applicable):

iv. Discarded

Client initials:

Partner initials (if applicable):

c) If applicable, in the event of both the deaths of the Client and Partner, we wish the Reproductive Material(s) to be: *

Please select one option for death of both.

i. Donated to infertile couples

Client initials:

Partner initials (if applicable):

ii. Donated for medical research

Client initials:

Partner initials (if applicable):

iii. Discarded

Client initials:

Partner initials (if applicable):

d) If applicable, in the event of the Client and Partner's divorce or separation, we wish the Reproductive Material(s) to be: *

Please select one option for divorce/separation.

i. Donated to infertile couples

Client initials:

Partner initials (if applicable):

ii. Donated for medical research

Client initials:

Partner initials (if applicable):

iii. Discarded

Client initials:

Partner initials (if applicable):

iv. Placed at the disposal of the Client in accordance with the provisions of the decree for divorce

Client initials:

Partner initials (if applicable):

Reproductive Material Disposition Preferences

e) In the event I/we notify FCLAB &/or Alpha Fertility in writing that I/we are unable to decide/agree on the future disposition of Reproductive Material(s) we wish the Reproductive Material(s) to be: *

Please select one option for this disposition scenario.

i. Donated to infertile couples

Client initials:

Partner initials (if applicable):

ii. Donated for medical research

Client initials:

Partner initials (if applicable):

iii. Discarded

Client initials:

Partner initials (if applicable):

f) I/We agree that in the event I/we fail to make one annual payment for storage, the Reproductive Material(s) will be: *

Please select one option for this disposition scenario.

i. Donated to infertile couples

Client initials:

Partner initials (if applicable):

ii. Donated for medical research

Client initials:

Partner initials (if applicable):

iii. Discarded

Client initials:

Partner initials (if applicable):

g) I/We understand that the Reproductive Material(s) will be stored for a time not to exceed the normal reproductive life of the Client (age 50 for females, age 65 for males). At that time I/we wish the Reproductive Material(s) to be: *

Please select one option for this disposition scenario.

i. Donated to infertile couples

Client initials:

Partner initials (if applicable):

ii. Donated for medical research

Client initials:

Partner initials (if applicable):

iii. Discarded

Client initials:

Partner initials (if applicable):

h) In the event I/we are no longer receiving assisted reproductive technology treatment and we have failed to inform FCLAB &/or Alpha Fertility of our current address and telephone number for a period of one (1) year I/we wish the Reproductive Material(s) to be: *

Please select one option for this disposition scenario.

i. Donated to infertile couples

Client initials:

Partner initials (if applicable):

ii. Donated for medical research

Client initials:

Partner initials (if applicable):

iii. Discarded

Client initials:

Partner initials (if applicable):

Electronic Signatures

Client Signature *

Partner Signature *

Guardian Signature *