This Acknowledgement Regarding Non-Discrimination, Patient Status and Patient Rights and Obligations (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")

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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.

Patient Status. Because RNCRH provides assisted reproduction Services to help patients reach their family building goals, patients’ relationship status and age are critical to ensure best care and compliance with medical, legal and regulatory requirements and guidelines and RNCRH’s policies. Patients are required to disclose their marital status, age, and confirm their intentions regarding parental status and obligations before patients begin treatment. Patients are also required to promptly disclose any change in relationship status during the course of treatment and may be required to provide appropriate legal documentation.

Third Party Arrangements. RNCRH provides that Patients using donor egg, sperm or embryo or a gestational carrier face additional requirements and considerations. Developing law as to same-sex marriage, and parentage for single, transgender, unmarried patients, co-parenting arrangements or polyamorous relationships may or may not adequately address patients’ or partners’ parental rights and the legal status of resulting children. Existing laws, which vary from state to state and from country to country, may either restrict or impose limitations on certain arrangements. In such cases, patients are strongly advised, and may be required, to engage independent experienced counsel in family law relating to assisted reproduction services.

Patient's Rights and Obligations. RNCRH strives to ensure that every patient, staff member and medical provider is treated with dignity, respect and consideration in a positive, non-hostile and non-violent healthcare environment where everyone feels safe. We expect all of our staff to behave in a compassionate and respectful manner and, in turn, expect all who enter our offices to do the same.

Effective date (last edited on): October 26, 2023