WPC& .7DSf4^LNf.7',@׮8&;pȵ]+V5RIEÚ,sybd)u1ҽRV+GL%M)*c4u [è>o=ua䱶0e^8>HqO6aϕ]-T{g,IP;SO9F}vm$aD}o ՁH*g+4n}*qδqm79bF}g,WYEg_ Ļ;zۘ5J_NJ9`:WVtx | H9#!AỲ. s <xss|1R1t-e4m3crUA˘r#'Ք-DV 4&X?^,xwRj+<eL4U> 0  0 0 0 0 0 0 0 0 0 0 0 0 0 0 0{ 0f 0N 06 0) 0 0  0 0 0 0 0 0n! 0J! B=" D/Z" 1e" 7"" 0 ###UNu% %%M%(%N%^ % 1u& 72x&w&4&& m&&\  `&Times New Roman' PROCREATIVE CRYOBANK, LLC 8Ronald P. Wilbois, M.D.80Ronald P. Wilbois, M.D. .   2V+S 0_level1  , >4` hp x (#%>23  ..  ;1` hp x (#%;  2S+S 0_level2  X ;1` hp x (#%;23  ..  ;1` hp x (#%;  2S+S 0_level3   ;1444` hp x (#%;23  ..  ;1` hp x (#%;  2P+S 0_level4   8.` ` ` hp x (#%823  ..  ;1` hp x (#%;  2P+S 0_level5   8.  hp x (#%823  ..  ;1` hp x (#%;  2M+S 0_level6   5+ hp x (#%523  ..  ;1` hp x (#%;  2M+S 0_level7  4 5+ hp x (#%523  ..  ;1` hp x (#%;  2J+S 0_level8  ` 2( hp x (#%223  ..  ;1` hp x (#%;  2J+S 0_level9   2(< <<hp x (#%223  ..  ;1` hp x (#%;  2VS 0_levsl1  , >4` hp x (#%>23  Ԁ  ;1` hp x (#%;  2SS 0_levsl2  X ;1` hp x (#%;23  Ԁ  ;1` hp x (#%;  2SS 0_levsl3   ;1444` hp x (#%;23  Ԁ  ;1` hp x (#%;  2PS 0_levsl4   8.` ` ` hp x (#%823  Ԁ  ;1` hp x (#%;  2PS 0_levsl5   8.  hp x (#%823  Ԁ  ;1` hp x (#%;  2MS 0_levsl6   5+ hp x (#%523  Ԁ  ;1` hp x (#%;  2MS 0_levsl7  4 5+ hp x (#%523  Ԁ  ;1` hp x (#%;  2JS 0_levsl8  ` 2( hp x (#%223  Ԁ  ;1` hp x (#%;  2JS 0_levsl9   2(< <<hp x (#%223  Ԁ  ;1` hp x (#%;  2VS 0_levnl1  , >4` hp x (#%>23   ;1` hp x (#%;  2SS 0_levnl2  X ;1` hp x (#%;23   ;1` hp x (#%;  2SS 0_levnl3   ;1444` hp x (#%;23   ;1` hp x (#%;  2PS 0_levnl4   8.` ` ` hp x (#%823   ;1` hp x (#%;  2PS 0_levnl5   8.  hp x (#%823   ;1` hp x (#%;  2MS 0_levnl6   5+ hp x (#%523   ;1` hp x (#%;  2MS 0_levnl7  4 5+ hp x (#%523   ;1` hp x (#%;  2JS 0_levnl8  ` 2( hp x (#%223   ;1` hp x (#%;  2JS 0_levnl9   2(< <<hp x (#%223   ;1` hp x (#%;  <:Default ParaXXX. ,Title      d )1dxd 35;AGMSY_11.a.i.1.a.i.1.a." i.#|x(U$X..      'XXX'XXXX'XTP05,,,,0(a Z6Times New Roman Regular'Xۣ. 3#37=CIQYag1.a.i.(1)(a)(i)1)a)-i)p-:i+00U  %U!X..      'XXX'XXXX'X  _       XX     P    ӀPROCREATIVECRYOBANK,LLC   x  P1#݌ X Ќ        P  XX 3009N.BallasRd.Suite352CSt.Louis,MO63131(314)9973620L݌ > Ќ          @݌̌          ݌̌   XX     /  AUTHORIZATIONFORRELEASEOFSEMEN/Y݌ {# Ќ           ݌̌          _  XX Iamreferring(patientsname)__________________________________toProcreativeCryobank,LLC,toobtainsemen G specimensforasassistedreproductionprocedure.Ihaveinformedmypatientoftherisksandlimitationsofassisted  reproductionprocedure.IauthorizehertoobtainthespecimensdirectlyfromProcreativeCryobank,LLC,ortotelephone m deliveryorderstomyofficeasneeded._݌  ,  Ќ            ݌̌          k  IunderstandthatispolicyofProcreativeCryobank,LLC,torenewthisAuthorizationforReleaseofSemenannually.k݌    Ќ          |   | ݌̌             Ifmypatientrequiresthereleaseofsemenforaperiodexceedingoneyear,IunderstandtheProcreativeCryobank,  (  willrequirerenewalofthisauthorization. ; ݌ ?  Ќ          U   U ݌̌             Iunderstandthateverypregnancyhasabout3%to4%riskofproducingachildwithabirthdefectormentalretardation.The e  lifetimeriskforallgeneticdisordersishigher.Geneticscreeningcanreducethisrisktosomeextent,butitcannoteliminate |$  theriskentirely.  ݌ ;  Ќ              ݌̌          @  MypatienthasagreedthatallspecimensobtainedbyProcreativeCryobankareforherpersonaluseonly.Theassisted a reproductionprocedurewillbeperformedundermydirectionandsupervision.@v݌ x  Ќ            ݌̌          =  ThespecimentypeIrecommendtohaveprovidedtomypatientis(Pleasecheckonlyone.)=s݌  Ќ          2  NOTE: Ifnospecimentypeisselected,wewillassume EITHERICIorIUI.2h݌ ] Ќ              V݌̌              _______ ` ONLYspecimenspreparedforIntracervicalinsemination(ICI).(StandardProcess)݌ 3 Ќ            ݌̌          >    ____ ` ONLYspecimenspreparedforintrauterineinsemination(IUI).Prewashedpriortofreezing)>݌ Y Ќ          _  _݌̌              ____ ` EITHERICIorIUI݌ / Ќ            ݌̌          I  DoctorsSignature:_____________________________________________________________________I݌ U  Ќ          A  Aw݌̌            LicenseNumber:________________________________________________________________________݌ +" Ќ            ݌̌          G  DateSigned:_________/____________/________________G}݌ Q$ Ќ            M݌̌            PrintNameofPhysician:__________________________________________________________________݌ '& Ќ            ݌̌             Hospital/CenterName:___________________________________________________________________ V݌  M( Ќ            K݌̌            Address:_______________________________________________________________________________݌ #"* Ќ            ݌̌             City/State/ZipCode:_____________________________________________________________________ Q ݌ #I!, Ќ          !  !G!݌̌          !  TelephoneNumber:(______)__________________________FaxNumber:(_______)_________________!!݌ %". Ќ          "  ""݌̌          #  SemenSpecimenshouldbedeliveredtothefollowingaddressifdifferentfromabove.:#P#݌ &E$0 Ќ           $   $B$݌̌          $  Name:_________________________________________________________________________________$$݌ (%2 Ќ          %  %%݌̌          &  Address:_______________________________________________________________________________&G&݌ )A'4 Ќ          '  ';'݌̌          '  ''݌̌          (  City/State/ZipCode:_____________________________________________________________________(M(݌ +~)7 Ќ           )   )C)݌̌          )  ))݌̌          *  *U*݌̌        P  *     `     h      p      x   (# **݌̌    P0-=      +   @ 0 @ 0 @ XXP2+,݌ X Ќ       P  ,  XX,-݌̌          |-  |--݌̌   XX     $.  PROCREATIVECRYOBANK,LLC$.N.݌ d Ќ        .  XX 3009N.BallasRd.Suite352CSt.Louis,MO63131(314)9973620..݌ J Ќ        /  //݌̌   XX     ^0  ^00݌̌        0  FROZENDONORSEMENSPECIMENAGREEMENT01݌  Ќ          H4` hp x (#%XH1  12݌̌        PK!(X zK  T7X` hp x (#%X%Tp2  Personal:( Pleaseprintortypeclearly)p2S3݌  z  Ќ        P P  Q:` hp x (#%'0*X%Q3  34݌̌        P  Z=X` hp x (#%'0*X0*Z4  ClientsName  f  (Last)______________________________(First)_________________________________Age________________  L  __4v5݌  2  Ќ        P  Q:` hp x (#%'0*X0*Qx6  x6 7݌̌        |  `7  MaritalStatus______________________________Spouses v  Name_____________________________________________________`77݌ \ Ќ        | P  Q4` hp x (#%X0*Q8  839݌̌        | P  W:` hp x (#%'0*X%W9  &%XX DriversLicense H No._______________________________State______________________Birthdate_____/______/____XX%&_9/:݌  Ќ          T;  T;;݌̌          ;  SocialSecurityNo.________________________________SpousesBus.  Telephone____________________________________;<݌  Ќ          <  <5=݌̌          =  HomeTelephone____________________________Business  Telephone____________________________________________==݌ g Ќ          -B''0*X0*->  Mailing ] Address________________________________________________________________________________ C __________________>?݌ ) Ќ          T:` hp x (#%'0*B''0*T@  @@݌̌          @  City__________________________________State____________________________Zip______________ m ___________@A݌ S Ќ          A  A-B݌̌          B  MothersMaiden ? ! Name_____________________________________________________________________________BB݌ %!" Ќ          C  (Thiswillbethepasswordtoyouraccount)CC݌ "# Ќ          ]D  ]DD݌̌        K!(X $!)K  D  FXXFinancialDgE݌  $!% Ќ          E  E,F݌̌   XXF       F  ChargeCardFXX#________________________________XXFExp.Date____/____FF݌ X&$' Ќ          G  󀀀___MasterCard___VisaGH݌ t'%( Ќ          H  HH݌̌          :I  Nameasitappearsonthecredit `)'* card:_____________________________________________________________:IpI݌ F*'+ Ќ          NJ  NJJ݌̌          J  Signatureof 2,)- cardholder:_________________________________________________________________________J K݌ -*. Ќ          K  KL݌̌          rL  Paymentmustbemadeatthetimeofyourorder.Wewillacceptcash,andtheabovechargecardsatthe /,0 timetheorderisplacedorpickedup.Checksmustbereceivedatleastthreedaysbeforeorderisplaced.I /-1 furtherunderstandthatcreditcardsarenottransferableaccordingtotherulesoftheissuingfinancial X institute.Thecreditcardholdermustauthorizeallpaymentsbycreditcardatthetimeofplacinganorder.rLL݌ > Ќ          N  N0O݌̌          O  I,theundersign,havereadtheabovestatementandacceptfullfinancialresponsibilityforallcharges * incurredbyme,ormydependents,forservicesrenderedbyProcreativeCryobank,LLC.OO݌  Ќ          P  P(Q݌̌          {Q  Clients  Signature______________________________________________________________________________{QQ݌  Ќ          R  RR݌̌          S  Spouses  v  Signature______________________________________________________________________________FXXSNS݌  \  Ќ   XXF     |   T7` hp x (#%'0*X0*TjT  jTU݌̌          cU  cUU݌̌        X `   E.hp x (#%'0*X0*EU       p      x   (#  h P3UV݌ |$  Ќ        |X ` T:` hp x (#%'0*X0*T_W  PROCREATIVECRYOBANK,LLC_WW݌ r Ќ        yX  XX 3009N.BallasRd.Suite352CSt.Louis,MO63131(314)9973620yXX݌ h Ќ        nY  nYY݌̌        Y  YZ݌̌   XX     Z  FROZENDONORSEMENSPECIMENAGREEMENTZZ݌ } Ќ          =[  XX =[s[݌̌        | P  Z=X` hp x (#%'0*X0*Z[  ThisAgreementismadebetweenProcreativeCryoBank,LLC,hereinreferredtoas PCBandtheundersigned,hereinreferredto B  Client.[\݌ Y Ќ          ]  ]]݌̌          (^  PCBisinthebusinessofcollecting,testing,storing,freezingandsellingdonorsemen,hereinreferredtoasthe specimen.Client  desirestopurchasetheSpecimenfromPCBforpurposesofreproductivetreatmentsuponthefollowingtermsandconditions:(^^^݌ ^ Ќ          _  _`݌̌    " (03-""  ,PK4` hp x (#%X0*K  P,Z=,` hp x (#%'0*X%Z`2  1  .3   X   PurchaseTerms:ClientShallselectthedonoroftheSpecimenfromthePCBdescriptioncatalogsandprofiles.PCBshallthendeliver T theSpecimenfromthesaiddonortoClient.ThefeestobepaidfortheSpecimenshallbecontainedonthePCBfeeschedulelast  publishedandispayableatthetimeoforder.TheSpecimencannotbereturnedforcredit.Intheeventthespecimenisdeterminedtobe z substandard,PCBshallrefundtotheClienttheamountpaidbytheClientfortheSpecimen.ClientagreestoreturnallPCBShippingtanks 9 promptlyandnotlaterthanthedateindicatedonthepackingslipenclosed.TheAuthorizationforReleaseofSemenfromsignedby P Clientsphysicianmustberenewedannually(pageP1oftheagreement).ClientagreestoobtainanewAuthorizationforReleaseof   Semensignedbyhercurrentphysician,oneyearafterdatelistedbeloworifClientchangesphysicians.`a݌ v! Ќ PP* X0*,X0**          T=X` hp x (#%'0*X0*Tf  f\g݌̌   ""  ,PK4` hp x (#%X0*K  P,]@,` hp x (#%'0*X%]g2  2  .3      ݀RepresentationofClient:ClientagreesthatPCBdoesnotwarrantorguaranteethequalificationsofanydonor,andthatindetermining l # whetheranydonorhascertainCharacteristicsorqualifications,PCB,shallberequiredtomakeonlysuchinvestigationsofanydonoras +!$ PCBshalldeemreasonablynecessary.gh݌ !% Ќ PP* X0*X0**        P  N7` hp x (#%'0*X0*Nj  jk݌̌        P  T=X` hp x (#%'0*X0*Tk  Clientagreesthatclientshallnotnow,oratanytime,requirenorexpectPCBtoobtainordivulgetoClientthenameofanydonor,norany #0!' otheridentifyinginformationcontainedinthefilesofPCB.Clientalsoagreesnottoseekthisinformationfromanyothersource.kol݌ G$!( Ќ          m  m1n݌̌          n  Clientagreesthatfollowinginseminationand/orassistedreproductiveprocedures,PCBwillretainallinformationandrecordswhichPCB %#* mayhaveastotheidentityofthedonorandtheClientforareasonableperiodoftime,afterwhichPCBmaydestroysaidinformationand &L$+ records.ItistheintentionofallpartiesthattheidentityofthedonorandClientshallbeandforeverremainanonymous.PCBhasan c' %, OpennessPolicywhichallowsrequestsforadditionaldonorinformationfromtheadultchild.Information,otherthanupdatedmedical "(%- information,isprovidedonlyifthereismutualconsentbetweenthedonorandadultchild.nn݌ (&. Ќ          q  q%r݌̌          xr  Clientunderstandsthatartificialinseminationand/orassistedreproductiveproceduresmaynotbesuccessful. Clientunderstandsthat *'(0 everypregnancyhasabout3%to4%riskofproducingachildwithabirthdefectormentalretardation.Thelifetimeriskforall >+(1 geneticdisordersishigher.Geneticscreeningcanreducethisrisktosomeextent,butitcannoteliminatetheriskentirely.xrr݌ +)2 Ќ          t  tu݌̌          Wu  ClientshallprovidePCBwithtimelyinformationonpregnanciesandbirthoutcomesinordertomonitordonorspecimenquality.Client -C+4 agreestonotifyPCBofallpregnanciesandbirthoutcomeswithin60daysoftheoccurrence.ClientauthorizesPCBtocontactClientif Z.,5 ClientceasesusingPCBservicesanddoesnotreportapregnancyorbirthoutcome.Wuu݌ /,6 Ќ          ~w  ~ww݌ /-7 Ќ          x  3.Indemnification:Clientagreesnottofile,initiateoraidanyclaim,demand,actionorcauseofactionfordamages,costs,lossofservice X expenseorcompensationfororonaccountoforhereafterarisingoutofanyserviceorproductprovidedbyPCBunderthisAgreement.xQx݌  Ќ          y  yz݌̌          qz  ClientagreestoindemnifyandholdharmlessPCBfromanylossand/orexpensesincurredbyClientinconnectionwithdemands,claims, ] actions,expensesand/orliabilitiesarisingoutofanyserviceorproductprovidedunderthisAgreement.qzz݌ t Ќ          |  |G|݌̌          |  ||݌̌          #}  ThisagreementshallbegovernedbythelawsoftheStateofMissouriandshallbebindinguponthepartieshereto,theirpersonal  representatives,estate,heirsandsuccessorsininterest.#}Y}݌ H Ќ          ~  ~~݌̌            Client:     4    <      D ProcreativeCryoBank,LLCP݌ >   Ќ          I  I݌̌          Ҁ  Dated:_________/___________/___________ <      D Dated:_________/_____________/___________Ҁ݌   Ќ          ClientsSignature:_______________________________________________  S  By:_________________________________________________݌ j   Ќ   SpousesSignature:_____________________________________________ 9   X   /0-9 ЇX XXԀPROCREATIVECRYOBANK,LLC     x P1 m     P  #XX҃#3009N.BallasRd.Suite352CSt.Louis,MO63131(314)9973620݌ c Ќ          ݌̌   XX     )  AUTHORIZATIONFORRELEASEOFSEMEN)S݌ Y Ќ        ܆  WAIVEROFRESPONSIBILITY܆݌ O Ќ          ݌̌          *݌̌          |  #XX # Iamreferring(patientsname)򀀀_toProcreativeCryobank,LLC,(PCB)to 1   obtainhissemenspecimensforassistedreproductionprocedureatmyfacility.Iunderstandmypatienthasinitiallybeentestedforthe   infectiousdiseasescreeningrequiredbyPCB.ProcreativeCryoBank,LLCfollowsthestandardsoftheAmericanAssociationof  W  TissueBanksandmakeeveryefforttoprotecttherecipientfromsexuallytransmitteddiseases.Mypatientunderstandsandhaselected n   towaivetherecommendedquarantineperiodof180days,andanyfurthertestingandwillnotholdPCBresponsible.Ihaveinformed -  mypatientsoftherisksandlimitationsofwaivingtheserecommendationsandassistedreproductionprocedure.Iauthorizetheabove   patientstoobtainthespecimensdirectlyfromProcreativeCryobank,LLC,ortotelephonedeliveryorderstomyofficeasneeded.|݌ S  Ќ          ݌̌            Ifmypatientrequiresthereleaseofsemenforaperiodexceedingoneyear,IunderstandProcreativeCryobank,LLCwillrequire I renewalofthisauthorization.;݌  Ќ          U  U݌̌          ޏ  MypatientshaveagreedthatallspecimensobtainedbyPCBarefortheirpersonaluseonly.Theassistedreproductionprocedurewill N beperformedundermydirectionandsupervision.MyPatientsfurtherunderstandoncehissemenspecimensaretakenoutofthe e  controlofPCB,theyagreenottofile,initiateoraidanyclaim,demand,actionorcauseofactionfordamages,costs,orcompensation $ fororonaccountoforhereafterarisingoutofanyserviceunderthisagreement.ޏ݌  Ќ          ͒݌̌            I,򀀀(Physician)havereadandunderstandthisdocumentand P alsoherebyreleaseProcreativeCryoBank,LLCfromanyliabilityassociatedwiththesespecimens(s).U݌  Ќ          ݌̌          e  e݌̌            DoctorsSignature:_____________________________________________________________________$݌ |$ Ќ            ݌̌          o  LicenseNumber:________________________________________________________________________o݌ ! Ќ          c  c݌̌            DateSigned:_________/____________/________________"݌ `# Ќ            ݌̌          E  PrintNameofPhysician:__________________________________________________________________E{݌ V % Ќ          <  <r݌̌          ś  Hospital/CenterName:___________________________________________________________________ś݌ !' Ќ            ݌̌          C  Address:_______________________________________________________________________________Cy݌ #:!) Ќ          7  7m݌̌            City/State/ZipCode:_____________________________________________________________________݌ 0%"+ Ќ            ݌̌          ?  TelephoneNumber:(______)__________________________FaxNumber:(_______)_________________?u݌ &v$- Ќ          6  6l݌̌            SemenSpecimenshouldbedeliveredtothefollowingaddressifdifferentfromabove.:݌ l(&/ Ќ            ݌̌          :  Name:_________________________________________________________________________________:p݌  *'1 Ќ          -  -c݌̌            Address:_______________________________________________________________________________݌ +P)3 Ќ            ݌̌          3  3i݌̌            City/State/ZipCode:____________________________________________________________________________________________݌ .+6 Ќ          ɧ       `     h      p   ɧ݌̌          ʨ