Clinics Onboarding

(to be completed by the Clinics director/technical supervisor and/or Clinics manager)

Clinics Details

Clinics Name*

Clinics Shipping Address*

Street Address*

Street Address Line 2

City*

State / Province*

Phone Number*

Clinic Name (if different from above)

Clinic Website

Lab Director/ Tech. Supervisor Name

First Name*

Last Name*

Lab Director/ Tech. Supervisor Title

Lab Director/ Tech. Supervisor Email

Shipping Contact Name (This will be the person who we will consider as the main point of contact for your clinic)

First Name

Last Name

Shipping Contact Email

Preferred Delivery Times (example: Mon-Fri 10am-2pm)

Nurse/Patient Coordinator's Name

First Name

Last Name

Nurse/Patient Coordinator's Email

Clinics Credentials

FDA Registration #

Tissue Bank License #

CAP #

Health Canada License #

Clinics Protocols and Outcomes

What vitrification/warming media do you routinely use?*

What vitrification device do you routinely use?*

Estimated number of IVF cycles in your lab annually?*

Estimated number of oocytes warming cycle annually?*

What is your lab cryopreservation recovery and survival rate for blastocyst embryos?*

What is your lab cryopreservation recovery and survival rate for frozen oocytes?*

What is fertilization rate for patients < 35-year-old (fresh + frozen)?*

What is your blastocyst formation rate for fresh donor eggs and patients < 35 y.o.?*

What is your blastocyst formation rate for frozen donor eggs and patients < 35 y.o.?*

Do you verify temperature in thaw/warming solution?*
YesNo

Do you have an annual competency evaluation for each embryologist that is specific for oocyte warming?*
YesNo

Is your Clinics qualified to receive frozen donor eggs from other egg banks?*
YesNo

Will your clinic accept frozen eggs from FDA approved clinic in Canada?
YesNo

If yes, please list egg banks:

Please provide a list of embryologists authorized to warm frozen oocytes at your clinic:

Full Name*

Title*

Email Address

# of years of experience

OUR REQUIREMENTS FOR ONGOING COLLABORATION AND CONDITIONS TO PROVIDE AN OUTCOME GUARANTEE:

Email Address

# of years of experience

Each embryologist should review Warming Video Instruction provided by Surrogacy4all
Each authorized embryologist should strictly adhere to Surrogacy4all warming protocol
Record the name and title of the person receiving and handling the frozen oocytes
Keep Surrogacy4all up to date on the embryologist in your lab who are authorized to warm frozen oocytes
Maintain documentation of each embryologists' warming performance and blastocyst development for Surrogacy4all warming
Performing ICSI on all frozen oocytes from Surrogacy4all, exactly 2 hours after warming (time of warming and ICSI should be documented)
Submitting to Surrogacy4all pictures of the recovered oocytes and created embryos prior to freezing or transferring. Add pictures of any poor-quality blastocyst that is discarded.
Submit the outcome for each batch of eggs:
1. Oocyte recovery
2. Fertilization
3. Blastocyst formation
4. Any PGT-a info (if applicable)
5. Maintain documentation of each embryologists' warming performance and blastocyst development for Surrogacy4all warming
6. Clinical pregnancy
7. Ongoing pregnancy
8. Live birth outcome

I certify this information submitted here is true and our program is committed to following Surrogacy4all requirements listed above:

Print Name*

First Name

Last Name

Professional Title*

Signature*
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Date

Clinics Onboarding