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ac/nowledge that as I/we proceed changes may occur in my/our treatment plan and I/we may be as/ed to sign additional consent "orms! ;! .elease/Indemni"ication! I/%e agree that Preserving Your egacy, Inc! shall not be held liable "or any actions, e0penses, or damages relating to the collection, "ree(ing, storage, release, loss, damage, or destruction o" the embryo(s)! I/we agree to indemni"y, de"end and hold harmless Preserving Your egacy, Inc! "rom and against any loss or damage sustained by Preserving Your egacy, Inc! as a result o" (a) the procedure provided the loss or damage does not result "rom Preserving Your egacy, Inc! negligence or pro"essional misconduct1 and (b) the legal status o" any o""spring or the e0istence or non4e0istence o" parental rights or obligations with respect to you or any other person whatsoever! &his release and indemni"ication shall survive termination o" this consent "or any reason whatsoever! <! =on"identiality! I understand that any in"ormation that is obtained in connection with my treatment and that can be used to identi"y me will remain con"idential! >y name and address will remain on "ile at the tissue ban/, and shall not be disclosed to any person or entity, e0cept upon my written in"ormed consent, or to authori(ed employees o" Preserving Your egacy, Inc! or as permitted by law! In addition, data "rom all I7' procedure will also be provided to the =enters "or $isease =ontrol and Prevention (the =$=)! &he #??- 'ertility =linic 2uccess .ate and =erti"ication *ct re,uires that =$= collect data on all assisted reproductive technology cycles per"ormed in the @nited 2tates annually and report success rates using this data! Aecause sensitive in"ormation is collected, the =$= applied "or and received an assurance o" con"identiality "or this pro:ect under the provisions o" the Public +ealth 2ervice *ct, 2ection 5BC (d)! &his means that any in"ormation that =$= has that identi"ies a gestational carrier will not be disclosed to anyone else without consent! *dditional in"ormation regarding how Preserving Your egacy, Inc! may use patient in"ormation is included in the Preserving Your egacy, Inc! Privacy 8otice! I/%e the undersigned have had the opportunity to have all o" my/our ,uestions about the Procedure answered to my/our satis"action! I/%e also understand the purpose, bene"its and ris/s involved in the Procedure! @nless treatment decisions change, this signed consent "orm will be considered valid "or one year! I" there are changes to these treatment decisions, a new consent "orm must be signed! INTENDING TO BE LEGALLY BOUND, the art!es hereto ha"e #a$se% th!s A&reement to be e'e#$te% as of the %ate f!rst abo"e wr!tten( AY_______________________ (Party #) _______________________ (8ame/Please Print) ______________________ ($ate) AY_______________________ (Party -) _______________________ (8ame/Please Print) ______________________ ($ate) AY_______________________ (Preserving Your egacy, Inc!)