□ Assisted reproduction (Insemination, IVF, ICSI)     □ Embryo Sorting (PGT)      
□ Fertility preservation   □ Patients with HIV / Hepatitis         □ Egg donation       
 

Date: ____ 

                                                                                                                              
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Name and cpr. of woman                                Name and cpr. of partner 

A - CONSENT FORM FROM ALL WOMEN WHO ARE TO RECEIVE TREATMENT  

I hereby consent to the treatment described above, and I declare that I have been informed of the effects, side-effects and risks of the treatment, including any use of sedatives and pain-relieving treatment without involvement of anesthetic staff as stipulated in the current rules of Rigshospitalet.  
 
Signature by woman and date:  
 
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B - CONSENT FORM FROM THE PARTNER  

I, the undersigned, hereby give consent

That my spouse/partner receive assisted reproduction treatment by a physician due to legal requirements contained in Sundhedsloven 
At the same time, I also declare, that I shall be the second parent of the child/children, who is/are conceived through the treatment, due to legal requirements contained in § 27 of Børneloven. 
 
Signature by partner and date: 
 
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C - CONSENT FORM CONCERNING CPR NUMBERS AND CONSENT IN THE PARTNER'S MEDICAL RECORDS 

I hereby give consent to my CPR no. being stated in my partner's medical records and that my consent form     will be kept with my partner's/donor's medical records. 
      
Signature by woman and date:                                Signature by partner and date:      
 
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D - CONSENT FORM - FREEZING OF EMBRYOS 

The undersigned hereby: 
 
□ Consent to the surplus eggs and embryos from our complete treatment course being frozen and later used during our treatment, if the eggs and embryos are of sufficiently good quality. 
□ Consent to embryos only being thawed and used if both parties agrees to this in writing, before each time one or more embryos are thawed. 
□ Confirm that we have been informed that frozen eggs and embryos that have not been used before I turn 46 years old will be destroyed in accordance with current legislation. 
□ Consent to the eggs being destroyed in the event of legal separation, divorce, or if the woman dies.  
 
Signature by woman and date:                                  Signature by partner and date:      
 
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E – CONSENT TO GATHERING INFORMATION REGARDING THE BIRTH 

The department shall notify Sundhedsstyrelsen about the results of the treatment, therefore it is important for us to know about the results of the treatment course of all pregnancies. By giving your consent, you hereby give the department permission to check your birth records 
 
Signature by woman and date:                                  Signature by partner and date:  
 
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F – CONSENT REGARDING EDUCATION AND DEVELOPMENT 

The undersigned, who is being treated at the Fertility Department at Rigshospitalet, hereby gives permission to eggs and fertilized eggs, which can not be used during treatment, and therefore have to be destroyed under any circumstances, can be used for educational purposes and training of the departments laboratory.  It shall be pointed out that non-useable eggs will be destroyed during training.  
 
Signature by woman and date:                                  Signature by partner and date:  
 
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G - CONSENT FORM FROM THE HUSBAND OR COHABITING MAN  

I, the undersigned, hereby consent to continued use by my partner of my frozen sperm or eggs fertilized with my sperm if I die during or after our treatment course. 
 
Signature by man and date: 
 
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H - CONSENT FORM FROM MEN WHO ARE TO HAVE SEMEN COLLECTED FROM THEIR TESTICLES (TESA)  

I hereby consent to the treatment described above, and I declare that I have been informed of the effects, side-effects and risks of the treatment, including any use of sedatives and pain-relieving treatment without involvement of anaesthetic staff as stipulated in the current rules of Rigshospitalet.  
 
Signature by man and date:  
 
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Endorsement by a health professional:                                                  Date: