female history

Female History MUST COMPLETE ALL QUESTIONS

Name: ________________________________ Date of Birth: ________________

Age: _______ Health Card: _______________________________

Height: _________ Weight: ________ Occupation: ____________________________

Race: _____________________ Ethnic background: __________________________

Total number of pregnancies: _______ Preterm births: _______ Term Births: ________

Miscarriage: _______ Abortions: _______ Ectopic Pregnancies: _______

Biochemical Pregnancies: _____

Why were you referred to our clinic? (check all that apply).

❏ Primary infertility (trying to get pregnant and have not been pregnant before)

❏ Secondary infertility (trying to get pregnant and have been pregnant before, even it

miscarried or terminated)

❏ Recurrent pregnancy loss (2 or more miscarriages)

❏ Oocyte(egg) freezing (currently not trying to become pregnant, but interested in

preserving your fertility)

❏ Other (please specify): _____________________________________________________

How long have you been trying to achieve pregnancy? _______________/months

How long have you been trying with current partner? _______________/months

DocuSign Envelope ID: 1F2C89E5-CD9D-405C-9C6F-42FBC0ED49DCDocuSign Envelope ID: EB5417D9-8BF1-442C-9D2C-F8B04A4CAD12DocuSign Envelope ID: C64A245B-B085-4FF7-98FA-B5875645D36FDocuSign Envelope ID: 8F7284BC-103D-4D13-8150-70454D170BA5DocuSign Envelope ID: DFA35FA7-9C7B-478A-AFD0-28C1FBE48D32DocuSign Envelope ID: CCEC4B4A-A127-4BC7-871F-B63F955B64F5

SHELBY SKELTON

DocuSign Envelope ID: 8A321CAA-36C3-4850-AE07-B4DAC84FB74C

0

United Kingdom

29

150

May 21, 1992

2166914768DE

1

5'9"

Caucasian

Project Manager Healthcare

0

00

X

1

16 months

16 months

0

Pregnancy Information:

Date

(mm/yy) Current

Partner Months to

Conception Difficulty

Conceiving Fertility

Treatment

Outcome Delivery

type

□ Yes

□ No

□ Yes

□ No

□ Yes

□ No

□ Term

□ Pre-term

□ Ectopic

□ Abortion

□ Miscarriage

□ Living

□ Biochemical

□ Vaginal

□ C-Section

□ Other

□ Yes

□ No

□ Yes

□ No

□ Yes

□ No

□Term

□Pre-term

□Ectopic

□Abortion

□Miscarriage

□Living

□Biochemical

□ Vaginal

□ C-Section

□ Other

□ Yes

□ No

□ Yes

□ No

□ Yes

□ No

□ Term

□ Pre-term

□ Ectopic

□ Abortion

□ Miscarriage

□ Living

□ Biochemical

□ Vaginal

□ C-Section

□ Other

□ Yes

□ No

□ Yes

□ No

□ Yes

□ No

□ Term

□ Pre-term

□ Ectopic

□ Abortion

□ Miscarriage

□ Living

□ Biochemical

□ Vaginal

□ C-Section

□ Other

□Yes

□No

□Yes

□No

□Yes

□No

□Term

□Pre-term

□Ectopic

□Abortion

□Miscarriage

□Living

□Biochemical

□Vaginal

□C-Section

□Other

DocuSign Envelope ID: 1F2C89E5-CD9D-405C-9C6F-42FBC0ED49DCDocuSign Envelope ID: EB5417D9-8BF1-442C-9D2C-F8B04A4CAD12DocuSign Envelope ID: C64A245B-B085-4FF7-98FA-B5875645D36FDocuSign Envelope ID: 8F7284BC-103D-4D13-8150-70454D170BA5DocuSign Envelope ID: DFA35FA7-9C7B-478A-AFD0-28C1FBE48D32DocuSign Envelope ID: CCEC4B4A-A127-4BC7-871F-B63F955B64F5DocuSign Envelope ID: 8A321CAA-36C3-4850-AE07-B4DAC84FB74C

X

24-Jan/21

X

X

4

X

When did you first start having your periods (age in years) ________________

Date of last menstrual period? (mm/dd/yyyy) ______________

How many days do you bleed for, on average? ______________________

Are your periods regular? □ Regular □ Irregular

If regular, how often do you get a period? (e.g. every 28 days) Every___________ Days

If irregular, what is the average range of your cycles? (e.g. every 30 to 45 days)

Every ________ to ________days

Do you ever have bleeding/spotting between periods? □ Yes □ No

If yes, specify details below.

Bleeding/spotting mid-cycle □ Yes □ No

Spotting just before periods □ Yes □ No

Spotting just after periods □ Yes □ No

Spotting after intercourse □ Yes □ No

Do you have pain with your periods? □ Yes □ No

□ Mild □ Moderate □ Severe

If yes, what do you take to the pain (if anything)? _____________________________________

Do you use ovulation predictor sticks when trying to conceive? □ Yes □ No

If yes, what evidence for ovulation did you see?

□A Positive test □Color change □Other: _____________________________

Have you ever used contraception in the past, either for contraception purposes or for other

reasons? □ Yes □ No

□Birth control Pills □IUD □Tubal Ligation (tubes tied) □Hormone Patch

□Injectable Hormones □Other: ___________________________________

Have you ever had a pap smear? □ Yes □ No

If yes, when was your last pap smear (approximate month and year)? _____________________


X

30

January 2020 I believe

09/29/2021

X

Positive LH test plus rise in BBT

4

X

X

16

35

X

X

Tylenol/advil

X

X

X

X

Have you ever had an abnormal pap smear? □ Yes □ No

If yes, what was the abnormality? ________________________________________

Do you have discharge or milk from the breast? □ Yes □ No

If yes, Specify details: ___________________________________________________________

Do you have issues with acne(pimples)? □ Yes □ No

Do you have issues with excessive growth of course, dark hair (e.g. on face, chest, back)?

□ Yes □ No

If yes, specify area and methods of removal (if any): _____________________________

What is your sexual orientation? _______________________________________

Do you ever have pain with intercourse? □ Yes □ No

If yes, when does it occur? □ Initial penetration

□ Deep penetration

□ Other: ___________

How often do you and your partner have intercourse? _______________/Week

Do you use lubricants with intercourse? □ Yes □ No

If yes, specify type: _____________________________________________________________

Have you ever had a sexually transmitted infection or pelvic inflammatory disease?

□ Gonorrhea □ Chlamydia □Herpes □Syphillis

□HPV(human papilloma virus) □HIV/AIDS


X

Pre-seed when in conception week, we also increase sex on conception week

X

Heterosexual

X

Average 1 time

X

X

X

Are you currently taking any medications? □ Yes □ No

If yes, provide details below:

Medication name Reason for medication

1.

2.

3.

4.

5.

Are you on a prenatal vitamin or folic acid alone? □ Yes □ No

If yes, specify what you are taking (e.g. Dose of folic acid): _____________________________

Do you have any known medication allergies, food allergies or other environmental factors?

□ Yes □ No

If yes, Specify the medication(s) and the reaction(s): ___________________________________

Have you ever had surgery? □ Yes □ No


Date

(yyyy)

Indication Type of Surgery Findings Complications

1.

2.

3.


X

None

X

Stomach surgery very young

X

X

1992 ish

Resolved

Open repair

1mg per day

Have you ever been diagnosed with HIV? □ Yes □ No

Have you ever had chicken pox? □ Yes □ No

Do you smoke cigarettes? □ Yes □ No

If yes, specify the number of cigarettes per day: _______________________________

Did you previously smoke cigarettes? □ Yes □ No

If yes, specify when you quit and the amount of cigarette for day or week: __________________

Do you drink alcohol? □ Yes □ No

□Socially Amount per week:_______ □Daily Amount per day:_______

□Alcoholic-Dependent

Do you consume caffeine (e.g. coffee, tea, pop)? □ Yes □ No

If yes, specify the type and amount per day or week: __________________________________

Do you use recreational drugs (e.g. Marijuana, Cocaine, etc.)? □ Yes □ No

If yes, specify the type and amount: ________________________________________________

Do you exercise? □ Yes □ No

If yes, Specify activity and frequency per day or week: _________________________________

Do you or anyone in your family have any of the following medical conditions:

Please check all that apply and state who Self, mother, father, brother, sister, child, Paternal

Grandmother, Paternal Grandfather, Maternal Grandmother, Maternal Grandfather

□Yes □No

❏ Early menopause _________________

❏ Endometriosis _____________________

❏ Infertility _________________________

❏ Recurrent pregnancy loss (3 or more consecutive miscarriages ______________

❏ Diabetes______________________

❏ Birth defects_____________________


X

X

X

X

X

X

Spin class/treadmill running

1 8oz cup of coffee per day

X

X

Marijuana occasionally

X

X

1

❏ Delayed puberty or pituitary tumor ________________

❏ Breast cancer______________

❏ Ovarian cancer_________________

❏ Cervical Cancer_________________

❏ Uterine Cancer__________________

❏ Cancer (type and who) ___________________________________________

❏ Bleeding disorder_________________________

❏ Chromosomal Abnormalities (in babies, e.g. Down’s syndrome) ______________

❏ Neural tube defects (e.g. Spina Bifida) ____________________

❏ Thyroid disease_____________________

❏ High blood pressure__________________________

If you answered self for any medical conditions stated above, specify details (e.g. disorder,

treatment, etc): ________________________________________________________________

____________________________________________________________________________

Have you or your current partner had a still born child or more than two first trimester

miscarriages? □ Yes □ No

If yes, specify (Still born or first trimester miscarriage and year): _________________________

____________________________________________________________________________


X

Male History

Please complete all questions

Name: _______________________________ Date of birth: ______________________

Age: ________ Health Card: ______________________________________

Height: _________ Weight: ________ Occupation: _____________________________

Race: _____________________ Ethnic background: ____________________________

Have you ever fathered a pregnancy before? □ Yes □ No

If yes,

Date

(mm/yy) Current

Partner

Months to

Conception

Difficulty

Conceiving Fertility

Treatment

Outcome Delivery

type

□ Yes

□ No

□ Yes

□ No

□ Yes

□ No

□ Term

□ Pre-term

□ Ectopic

□ Abortion

□ Miscarriage

□ Living

□ Biochemical

□ Vaginal

□ C-Section

□ Other

□ Yes

□ No

□ Yes

□ No

□ Yes

□ No

□Term

□Pre-term

□Ectopic

□Abortion

□Miscarriage

□Living

□Biochemical

□ Vaginal

□ C-Section

□ Other

□ Yes

□ No

□ Yes

□ No

□ Yes

□ No

□ Term

□ Pre-term

□ Ectopic

□ Abortion

□ Miscarriage

□ Living

□ Biochemical

□ Vaginal

□ C-Section

□ Other

DocuSign Envelope ID: 9E1FF729-B7FB-4852-9FBC-92EFD582CB0ADocuSign Envelope ID: 7D70A235-6794-414C-B650-541924B72DA3DocuSign Envelope ID: 2C3ACA3C-C09A-4446-B548-503708B046E4DocuSign Envelope ID: 6692A61A-67D8-4EE6-A36D-3ECACD8E85A7DocuSign Envelope ID: E2A3BED9-F887-44C4-A0A7-B883D6271E4ADocuSign Envelope ID: 2A5AFBF4-E89C-4B2F-8C74-6D8F83D4E703

STEVEN SKELTON


5450226013FL

5'10"

28

180LBS

May 4 1993

United Kingdom? Caucasian

X

Warehouse Manager

Are you currently taking any medications? □ Yes □ No


Medication name Reason for medication

1.

2.

3.

4.

5.

Have you ever had surgery? □ Yes □ No


Date Indication Surgery Finding Complications

□Yes

□No

□Yes

□No

□Yes

□No

Have you been exposed and/or treated for any sexually transmitted infections? □ Yes □ No

If yes,

Infection Results/Comment

Do you have any known medication, food, or other environmental factors allergies?

□ Yes □ No

If yes, specify the medication(s) and the reaction(s): ___________________________________

______________________________________________________________________________

______________________________________________________________________________

DocuSign Envelope ID: 9E1FF729-B7FB-4852-9FBC-92EFD582CB0ADocuSign Envelope ID: 7D70A235-6794-414C-B650-541924B72DA3DocuSign Envelope ID: 2C3ACA3C-C09A-4446-B548-503708B046E4DocuSign Envelope ID: 6692A61A-67D8-4EE6-A36D-3ECACD8E85A7DocuSign Envelope ID: E2A3BED9-F887-44C4-A0A7-B883D6271E4ADocuSign Envelope ID: 2A5AFBF4-E89C-4B2F-8C74-6D8F83D4E703DocuSign Envelope ID: 8A321CAA-36C3-4850-AE07-B4DAC84FB74C

X

X

X

X

Repaired

ACL Repair

X

Torn ACL

Sept 12th 2012

Have you ever had mumps as a teenager? □ Yes □ No

If yes, at what age: _________________

Do you have issues with sexual performance, including any of the following?

Trouble getting an erection □ Yes □ No

Issues with ejaculating □ Yes □ No

Other: ________________________________________________

Are you taking any of the following?

Propecia □ Yes □ No

Rogaine □ Yes □ No

Testosterone □ Yes □ No

Have you ever had a vasectomy? □Yes □No

Have you ever had surgery on the testicles? □ Yes □ No

Did you have an undescended testicle(s) at birth? □ Yes □ No

If yes, specify details: _____________________________________________________

Have you had any of the following medical conditions related to the groin area (penis and

testicles):

Injury (significant injury, requiring medical care) □ Yes □ No

Surgery (e.g., Hernia repair, other) □ Yes □ No

Other: ______________________________________________________

Do you smoke cigarettes? □ Yes □ No

If yes, specify the number of cigarettes per day: _________________________

Did you previously smoke cigarettes? □ Yes □ No

If yes, specify when did you quit: __________________________________________________


X

X

X

X

X

May 2018

X

X

X

X

X

X

X

X

Do you drink alcohol? □ Yes □ No

If yes, □ Socially—how many drinks per week? ____________

□ Daily—How many drinks per day? _______________

□ Alcoholic—How many drinks per day? ____________

Do you consume caffeine (e.g., Coffee, tea, pop)? □ Yes □ No

If yes, specify type and amount per day or week: _______________________________

Do you use recreational drugs (e.g., Marijuana, cocaine, etc.)? □ Yes □ No

If yes, specify the type and amount: _________________________________________

Do you use hot tubs? □ Yes □ No

If yes, How often per week? _____________ For how long? ___________ Minutes

Are you exposed to any chemicals or toxins? Yes No

If yes, which ones: ______________________________________________________________

Do you or anyone in your family have any of the following medical conditions:

Please indicate who: Self, Mother, Father, Brother, Sister, Child, Grandmother,

Grandfather

❏ Infertility_________________

❏ Delayed puberty or pituitary tumor______________

❏ Cancer_____________

❏ Chromosomal abnormalities (in babies, e.g. Down’s syndrome)

________________

❏ Neural tube defects (e.g. Spina Bifida) _____________________

❏ Thyroid Disease______________________

❏ High blood pressure___________________

❏ High cholesterol______________________

❏ Diabetes ________________

❏ Other:______________________________________________________

____________________________________________________________

____________________________________________________________


X

X

X

Father

Father

1 8oz coffee, 1 can of pop

X

X

X

X

Grandmother

X

X

2

Father

X

PATIENT FEE SCHEDULE

Effective June 1, 2021

INTRAUTERINE INSEMINATION (IUI)/ DONOR SPERM INSEMINATION (DI) COST

IUI cycle monitoring and procedure Funded

Sperm preparation for IUI – fresh/frozen/donor $750.00

IN-VITRO FERTILIZATION (IVF) PROCEDURES IVF Cycle (includes Physician consult, egg retrieval & ICSI) $11,000.00

Embryo freezing $1,100.00

First frozen embryo transfer following a freeze all cycle $1,500.00

Frozen embryo transfer (FET) cycle $2,100.00

Frozen oocyte cycle (includes physician consult, egg thaw, ICSI) $7,500.00

ELECTIVE EGG FREEZING AND SPERM BANKING Sperm or surgical sample freezing $500.00

Egg freezing cycle (includes physician consult, egg retrieval, egg freezing) $7,750.00

ADDITIONAL IVF COSTS Sperm retrieval by urologist (TESA/PESA) $1,500.00

ERA I (1st sample) by Igenomix $1,250.00

ERA by Igenomix (2nd sample/repeat test) $ 600.00

EMMA & ALICE by Igenomix (1st sample) $1,100.00

EMMA & ALICE by Igenomix (2nd sample) $750.00

EndomTRIO by Igenomix (1st sample) $1,500.00

EndomTrio by Igenomix (2nd sample) $1,100.00

PRODUCTS OF CONCEPTION TESTING by Igenomix $700.00

PRE-IMPLANTATION GENETIC TESTING (PGT-A)

Igenomix (including biopsy & freezing) payment directly to Generation Fertility

1 Embryo $3,000.00

Add $300 for each additional embryo

Consultation, biopsy and freezing for any other lab $2,750

Outside lab fees for genetic analysis not included. A quote will be provided prior to cycle start

For PGT-M and PGT SR please ask billing for the additional costs

Sperm DNA fragmentation test $250.00

DIRECTED DONATION PROGRAM (KNOWN DONOR)

Program management fee $5,000.00

DocuSign Envelope ID: 2204B8B6-C249-40EC-9E5A-0A7DDFA17FC9DocuSign Envelope ID: 8F3A69CF-3770-4C18-973D-F3011F589150DocuSign Envelope ID: 8A321CAA-36C3-4850-AE07-B4DAC84FB74C

STORAGE FEES Annual storage fee for embryos, eggs or sperm (plus HST) $950.00 Payable immediately and on each anniversary of the original freeze date Several sperm samples can be stored as one batch if completed within 14 days of first sample Sperm, eggs, or embryos stored less than 3 months will be refunded storage fee

OTHER Anti-Mullerian Hormone (AMH) $125.00

Chart management fee- intercourse cycles (non-refundable) $200.00

Receipt and handling of specimens (from outside facility) $100.00

Transferring out embryos, eggs or sperm $500.00

Missed appointment $100.00

Satellite monitoring (non-refundable) $2,500.00

Insurance letter/physician Letter $30.00

Copy of medical record (plus HST) $100.00

TOTAL

FEE POLICY

• For your convenience we accept the following forms of payment: debit, certified cheque, bank draft

and all major credit cards. We cannot accept cash or personal cheques.

• Medication costs are not included and cannot be returned or refunded once purchased.

• All fees are in Canadian dollars.

• Funded cycles are available through the Ontario Fertility Program

CANCELLED OR CONVERTED CYCLE COSTS

• Cycles may be cancelled.

• Private pay IVF cycle converted to IUI cycle will be charged the sperm preparation fee of $750 and the

cycle monitoring fee of $725. Private IVF cancelled and not converted to IUI will be charged only the cycle

monitoring fee of $725.

REFUND POLICY

• Outstanding credits can be refunded or utilized towards future cycles.

• In certain cases, the desired outcomes may not be achieved yet our fees are non-refundable.

• You will be reimbursed any fees for services not provided.

• Egg retrieval with no eggs will be refunded $5,000 of the IVF treatment cycle fee.

Full payment of fees is due when patients initiate treatment (day 3 of menses). I/We understand the fees quoted

as per treatment cycle. I/We have read and understand the financial guidelines and fees. I understand all fees

and payment terms.

____________________________________ _______________________________ Patient's Signature Date

_____________________________________ _______________________________

Partner's Signature (if applicable) Date

DocuSign Envelope ID: 2204B8B6-C249-40EC-9E5A-0A7DDFA17FC9DocuSign Envelope ID: 8F3A69CF-3770-4C18-973D-F3011F589150DocuSign Envelope ID: 8A321CAA-36C3-4850-AE07-B4DAC84FB74C

PATIENT INFORMATION

LAST NAME (As it appears on your health card)

FIRST NAME (As it appears on your health card)

HEALTH CARD NUMBER VERSION CODE

DATE OF BIRTH / /

TELEPHONE

Day Month Year

WORK:( ) - EXT:

HOME:( ) -

PHONE # WHERE WE CAN LEAVE A MESSAGE

ADDRESS CITY PROVINCE POSTAL CODE

E-MAIL

REFERRING DOCTOR ADDRESS

FAMILY DOCTOR (if other than above)

PHARMACY NAME & PHONE #

PARTNER’S INFORMATION

LAST NAME (As it appears on your health card)

FIRST NAME (As it appears on your health card)

HEALTH CARD NUMBER VERSION CODE

DATE OF BIRTH / /

TELEPHONE

Day Month Year

WORK:( ) - EXT:

HOME:( ) -

PHONE # WHERE WE CAN LEAVE A MESSAGE

ADDRESS CITY

PROVINCE POSTAL CODE

E-MAIL

REFERRING DOCTOR ADDRESS

FAMILY DOCTOR (if other than above)

DocuSign Envelope ID: E14DED4F-B2AA-4D19-BE3A-0038D2112B1CDocuSign Envelope ID: 25E2BE3C-E3AC-42D6-9C0F-206971C4345FDocuSign Envelope ID: 83B500CA-C32B-4449-BF7A-17A6F146B9E4DocuSign Envelope ID: C5ACA777-1C10-4BE6-9E7E-9A7F798BC664

SKELTON

SHELBY

[email protected]

STEVEN

SKELTON

05/04/93

[email protected]


Same as above

L0G1M0

21/05/1992

451

Suite 202 29 Toronto Street South, Uxbridge ON L9P 1V9

Mount Albert

416-451-7221

I.D.A Ben's Pharmacy (Mount Albert) 905.473.2401

4 Robert Hunter Crescent

DE2166914768

7221

Ontario

416

5450226013FL

660

4 robert hunter crescent

Dr.Wong

mount albert

416

4166604736

ontario

29 Toronto St S, Uxbridge, ON L9P 1V9

sz7373964

4736

l0g1m0

Certificate Of CompletionEnvelope Id: 8A321CAA36C34850AE07B4DAC84FB74C Status: Completed

Subject: Please DocuSign consent

Source Envelope:

Document Pages: 14 Signatures: 0 Envelope Originator:

Certificate Pages: 6 Initials: 0 Procrea Fertility

AutoNav: Enabled

EnvelopeId Stamping: Enabled

Time Zone: (UTC-08:00) Pacific Time (US & Canada)

400-955 Major Mackenzie Drive West

Vaughan, ON L6A 4P9

[email protected]

IP Address: 18.223.243.152

Record TrackingStatus: Original

10/13/2021 6:22:24 AM

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[email protected]

Location: DocuSign

Signer Events Signature TimestampSHELBY SKELTON

[email protected]

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STEVEN SKELTON

[email protected]

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Wendy Corvelo

[email protected]

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Envelope Summary Events Status TimestampsEnvelope Sent Hashed/Encrypted 10/13/2021 6:22:29 AM

Certified Delivered Security Checked 10/19/2021 10:14:11 AM

Envelope Summary Events Status TimestampsSigning Complete Security Checked 10/19/2021 10:14:13 AM

Completed Security Checked 10/19/2021 10:14:18 AM

Payment Events Status Timestamps

Electronic Record and Signature Disclosure

ELECTRONIC RECORD AND SIGNATURE DISCLOSURE

From time to time, Procrea Fertility (we, us or Company) may be required by law to provide to

you certain written notices or disclosures. Described below are the terms and conditions for

providing to you such notices and disclosures electronically through the DocuSign system.

Please read the information below carefully and thoroughly, and if you can access this

information electronically to your satisfaction and agree to this Electronic Record and Signature

Disclosure (ERSD), please confirm your agreement by selecting the check-box next to ‘I agree to

use electronic records and signatures’ before clicking ‘CONTINUE’ within the DocuSign

system.

Getting paper copies

At any time, you may request from us a paper copy of any record provided or made available

electronically to you by us. You will have the ability to download and print documents we send

to you through the DocuSign system during and immediately after the signing session and, if you

elect to create a DocuSign account, you may access the documents for a limited period of time

(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to

send you paper copies of any such documents from our office to you, you will be charged a

$0.00 per-page fee. You may request delivery of such paper copies from us by following the

procedure described below.

Withdrawing your consent

If you decide to receive notices and disclosures from us electronically, you may at any time

change your mind and tell us that thereafter you want to receive required notices and disclosures

only in paper format. How you must inform us of your decision to receive future notices and

disclosure in paper format and withdraw your consent to receive notices and disclosures

electronically is described below.

Consequences of changing your mind

If you elect to receive required notices and disclosures only in paper format, it will slow the

speed at which we can complete certain steps in transactions with you and delivering services to

you because we will need first to send the required notices or disclosures to you in paper format,

and then wait until we receive back from you your acknowledgment of your receipt of such

paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to

receive required notices and consents electronically from us or to sign electronically documents

from us.

All notices and disclosures will be sent to you electronically

Electronic Record and Signature Disclosure created on: 4/6/2021 1:07:46 PMParties agreed to: SHELBY SKELTON, STEVEN SKELTON, Wendy Corvelo

Unless you tell us otherwise in accordance with the procedures described herein, we will provide

electronically to you through the DocuSign system all required notices, disclosures,

authorizations, acknowledgements, and other documents that are required to be provided or made

available to you during the course of our relationship with you. To reduce the chance of you

inadvertently not receiving any notice or disclosure, we prefer to provide all of the required

notices and disclosures to you by the same method and to the same address that you have given

us. Thus, you can receive all the disclosures and notices electronically or in paper format through

the paper mail delivery system. If you do not agree with this process, please let us know as

described below. Please also see the paragraph immediately above that describes the

consequences of your electing not to receive delivery of the notices and disclosures

electronically from us.

How to contact Procrea Fertility:

You may contact us to let us know of your changes as to how we may contact you electronically,

to request paper copies of certain information from us, and to withdraw your prior consent to

receive notices and disclosures electronically as follows:

To contact us by email send messages to: [email protected]

To advise Procrea Fertility of your new email address

To let us know of a change in your email address where we should send notices and disclosures

electronically to you, you must send an email message to us

at [email protected] and in the body of such request you must state: your

previous email address, your new email address. We do not require any other information from

you to change your email address.

If you created a DocuSign account, you may update it with your new email address through your

account preferences.

To request paper copies from Procrea Fertility

To request delivery from us of paper copies of the notices and disclosures previously provided

by us to you electronically, you must send us an email

to [email protected] and in the body of such request you must state your

email address, full name, mailing address, and telephone number. We will bill you for any fees at

that time, if any.

To withdraw your consent with Procrea Fertility

To inform us that you no longer wish to receive future notices and disclosures in electronic

format you may:

i. decline to sign a document from within your signing session, and on the subsequent page,

select the check-box indicating you wish to withdraw your consent, or you may;

ii. send us an email to [email protected] and in the body of such request

you must state your email, full name, mailing address, and telephone number. We do not need

any other information from you to withdraw consent.. The consequences of your withdrawing

consent for online documents will be that transactions may take a longer time to process..

Required hardware and software

The minimum system requirements for using the DocuSign system may change over time. The

current system requirements are found here: https://support.docusign.com/guides/signer-guide-

signing-system-requirements.

Acknowledging your access and consent to receive and sign documents electronically

To confirm to us that you can access this information electronically, which will be similar to

other electronic notices and disclosures that we will provide to you, please confirm that you have

read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for

your future reference and access; or (ii) that you are able to email this ERSD to an email address

where you will be able to print on paper or save it for your future reference and access. Further,

if you consent to receiving notices and disclosures exclusively in electronic format as described

herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before

clicking ‘CONTINUE’ within the DocuSign system.

By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm

that:

You can access and read this Electronic Record and Signature Disclosure; and

You can print on paper this Electronic Record and Signature Disclosure, or save or send

this Electronic Record and Disclosure to a location where you can print it, for future

reference and access; and

Until or unless you notify Procrea Fertility as described above, you consent to receive

exclusively through electronic means all notices, disclosures, authorizations,

acknowledgements, and other documents that are required to be provided or made

available to you by Procrea Fertility during the course of your relationship with Procrea

Fertility.

https://support.docusign.com/guides/signer-guide-signing-system-requirements

https://support.docusign.com/guides/signer-guide-signing-system-requirements

female history

Documents