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Request and Authorization for Micromanipulation of - Duke Fertility - dukefertilitycenter

Request and Authorization for Micromanipulation of - Duke Fertility - dukefertilitycenter 2025

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The document is a consent form for the micromanipulation of oocytes (eggs) for assisted fertilization, specifically through IntraCytoplasmic Sperm Injection (ICSI) at Duke University Medical Center. It outlines the procedure, associated risks and benefits, alternative options, economic considerations, and confirms the patient's voluntary participation and understanding of the treatment. The patient acknowledges potential risks such as damage to oocytes and polyspermic fertilization while consenting to the procedure.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name in the designated field. This is crucial for identifying the individual undergoing the procedure.
Review the description of the procedure carefully. Ensure you understand that this involves IntraCytoplasmic Sperm Injection (ICSI) and conventional insemination options.
Acknowledge and check any risks associated with the procedure, such as potential damage to oocytes or birth defects, ensuring you are fully informed.
Consider alternative options provided in the form, such as proceeding without micromanipulation or using donor sperm, and indicate your choice if required.
Sign and date the form at the bottom to confirm your consent. Ensure a witness also signs where indicated.

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