Pre-Implantation Genetic Testing (PGT) Informed Consent

# Pre-Implantation Genetic Testing (PGT) Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. Genetic testing of embryos raises medical, ethical, and legal considerations; genetic counseling is strongly recommended before signing. This document records your voluntary informed consent to pre-implantation genetic testing (PGT) of embryos created through in vitro fertilization (IVF). Your reproductive endocrinologist or a qualified designee has discussed, or will discuss, the following information with you. Please read carefully and ask any questions before signing. --- ## Patient Information **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number (if known):** ___________ **Partner / Co-patient Name (if applicable):** ___________ **Treating Physician / Provider:** ___________ **Facility / Clinic / Genetics Laboratory:** ___________ **IVF Cycle Date (estimated):** ___________ --- ## 1. Indication and Type of PGT **PGT type requested:** ___________ **Clinical indication / reason for testing:** ___________ **Genetic condition or chromosomal rearrangement being tested for (if PGT-M or PGT-SR):** ___________ --- ## 2. Description of the Procedure ### Step 1 — IVF and Embryo Culture