This Acknowledgement Regarding Non-Discrimination (this “Acknowledgement”) applies to all treatment(s), procedure(s) or service(s) (the “Services”) I, the patient, and my partner(s), as applicable, will receive from River North Center for Reproductive Health ("RNCRH")

NON-DISCRIMINATION NOTICE

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Non-Discrimination. I/We acknowledge that RNCRH does not discriminate against any person on the basis of race, color, national origin, disability, age, marital status, sex, sexual orientation, gender identity or expression, in fertility services and treatment. RNCRH will not deny assisted reproductive services to, and does not discriminate against, individuals presenting in a non-traditional relationship (e.g.., co- parenting, tri-parenting), but because laws determining parentage among non-traditional families, such as polyamorous relationships, are either non-existent or developing and may vary from state to state, RNCRH does not currently accommodate requests for three or more persons to be treated as “parents” under its informed consents. Until such time as there is more clarity in the legal and regulatory landscapes for non-traditional families, patients will be required to identify which of the individuals will be medically treated as the intended parent(s) and which of the individuals is acting in either the capacity of a donor (contributing gametes or embryos) and/or a gestational carrier and/or a sexually intimate partner in a co- or tri-parenting relationship. As mentioned below, appropriate legal agreement confirmations and/or legal counseling would be required, in addition to medical and psychosocial screening.

Effective date (last edited on): 3/27/25