Centre for Reproductive Medicine

Centre for Reproductive Medicine 1 Consent Form

University Hospital Clifford Bridge Road Coventry CV2 2DX Tel: 024 76 964000 Indicators of Oocyte and Embryo Development Centre Number: 0013 Study Number: 04/Q2802/26 Name of Researcher: Prof Geraldine Hartshorne Please initial box 1. I confirm that I have read and understand the Information patient partner sheet dated 20 March 2017 (version 7) for the above study and have had the opportunity to ask questions……….……………………..

2. I understand that my participation is voluntary and that I am free to withdraw (by written confirmation to the principal investigator) at any time until any samples are used, without giving any reason. My medical care or legal rights will not be affected……..…..

3. I understand that responsible individuals at the Centre for Reproductive Medicine may look at my medical notes. I give permission for them to collect anonymised medical history data………

4. I agree to take part in the above study……………………………………

5. I wish to offer the following material to research

 Eggs (immature or unfertilised) ………………………

 Fresh embryos (unsuitable for cryopreservation)…...

 Frozen embryos (no longer required)…………

6. At the end of the study, I agree that my anonymised material can be kept for future research…………………………………………….

______Name of Female Patient Date Signature

______Name of Male Patient Date Signature

______Name of Person taking consent Date Signature (if different from researcher)

______Researcher Date Signature

Author: G Hartshorne Note: This document is not controlled if printed. 1 Document Location: QM computer, I drive (consent forms / research), website Reference: Quality/consent forms/donate research Version: EMB-CO-000034V7 Review Date: May 2018 Centre for Reproductive Medicine 2 Consent Form

1 for patient 1 for researcher 1 to be kept with hospital notes consent form version 7, 20 March 2017

Author: G Hartshorne Note: This document is not controlled if printed. 2 Document Location: QM computer, I drive (consent forms / research), website Reference: Quality/consent forms/donate research Version: EMB-CO-000034V7 Review Date: May 2018