Example 2: Patient Consent For Treatment During The Covid-19 Pandemic


  1. My care team and PRACTICE NAME have discussed with me the impact of COVID-19 on my fertility treatments.

  2. I agree and understand:

    • PRACTICE NAME and my care team will provide updates regarding the pandemic and its impact on my treatment.

    • I understand that my cycle may be CANCELED if new information mandates cancellation for patient/baby safety or the clinic is unable to support treatment cycles.

    • If I am diagnosed with COVID-19, am directly exposed to COVID-19 or am suspected to have COVID-19 based on symptoms (even without a positive test), SRM will not continue with my treatment cycle. I understand that the expenses occurring to date will not be reimbursed.

    • The impact of COVID-19 on pregnancy are unknown. Some guidance societies have recommended a strategy to minimize pregnancy during this crisis.  I understand that the risks could include miscarriage, stillbirth, preterm birth and other unknown impacts on pregnancy.

    • High fever from any cause, including COVID-19, in the first trimester of pregnancy may be associated with an increased risk of birth defects. Covid-19 or seasonal influenza in the third trimester of pregnancy may be more likely to lead to pneumonia.  Cases of pneumonia in pregnancy may be more severe and require hospitalization and may lead to maternal and fetal compromise.  
  3. I (and my partner if applicable) have read and understand everything in this Consent for Treatment During the COVID-19 Pandemic. I have also been provided a copy of Information for ART Patients During the COVID-19 Pandemic. (This document can be individually developed by SART members balancing providing information without overwhelming the patient) I have been given the opportunity to ask questions relating to this consent and my questions have been answered to my satisfaction.  I understand that I can contact PRACTICE NAME if I have further questions.

By my/our signatures, below I/We confirm that I/we have read the above, information on COVID-19, have had an opportunity to discuss this information and our treatment plan with the treating physician, and agree to continue fertility treatment, including ART (if indicated) at this time.

Consent form example 1 signatures



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