Fertility Nurse Care Patient Agreement

This Agreement is between the patient identified above (the “Patient”) and Fertility Nurse Care LLC, through Geraldine Eslava, RN (the “Nurse”). It covers limited, private-pay nursing support for administration of fertility medication in the Patient’s home or another agreed location.

The Nurse acts as an independent registered nurse and is not an employee, agent, or representative of the Patient’s physician, fertility clinic, pharmacy, or medication manufacturer. The Nurse does not prescribe or independently select, approve, or change the Patient’s treatment plan.

1 Services

The Nurse may administer subcutaneous or intramuscular fertility medication, provide injection education, assist with medication preparation, perform a limited assessment related to immediate administration, and document the service. Virtual support may be provided only for administration education and does not include treatment management.

All services remain subject to the Nurse’s license, competency, professional judgment, and lawful scope of practice. The Nurse may refuse, pause, or stop a service when it cannot be performed safely or lawfully.

2 Existing Valid Physician or Authorized Prescriber Order

The Nurse administers medication only to carry out an existing, current, valid order issued for the Patient by a physician or other healthcare professional legally authorized to prescribe the medication. Before administration, the Patient must provide the Nurse with the written order, clinic medication calendar, portal instructions, prescription label, or other reliable provider-issued documentation showing the following:

Patient name and medication name;

Prescribed dose, concentration or formulation, and route;

Date and exact administration time, when time-sensitive;

Mixing or preparation directions and any special instructions; and

Prescriber or fertility clinic identification.

The Patient authorizes the Nurse to rely on the provider-issued information supplied by the Patient. The Nurse does not independently create, renew, or modify an order and does not routinely contact the prescriber or clinic to verify or clarify instructions. If the documentation is missing, expired, incomplete, conflicting, or unclear, the Nurse will not administer the medication unless the Patient first obtains adequate clarification from the prescribing provider.

3 Patient Must Supply Medication and Supplies

The Patient is solely responsible for obtaining and having on hand at the scheduled visit the correct medication prescribed and dispensed for the Patient. Fertility Nurse Care LLC and the Nurse do not purchase, dispense, deliver, replace, or supply prescription medication.

The Patient must also provide all manufacturer- or pharmacy-supplied items needed for administration, including the correct syringes, needles, pen devices, cartridges, diluent, mixing equipment, alcohol pads, gauze, and sharps container, as applicable. Medication must be unopened when appropriate, unexpired, undamaged, and stored as directed by the prescriber, pharmacy, and manufacturer.

If the medication, supplies, or provider-issued instructions are not available or do not match, the visit may be delayed, ended, or treated as a late cancellation. The Nurse will not substitute another medication, concentration, device, or supply when doing so would be unsafe or outside the order or scope of practice.

4 Limits of the Nurse’s Role

The Patient understands that the Nurse does not:

Diagnose infertility or any other condition;

Prescribe, select, recommend, start, stop, substitute, or adjust medication;

Change a dose, route, date, time, frequency, or treatment protocol;

Interpret laboratory or ultrasound results to make treatment decisions;

Determine whether a fertility cycle should continue, change, or be canceled;

Treat complications or provide emergency medical care; or

Guarantee pregnancy, embryo development, live birth, or any other fertility outcome.

The Patient’s prescribing provider remains responsible for the treatment plan, monitoring, medical decisions, and management of side effects or complications. Treatment questions must be directed to that provider.

5 Patient Responsibilities

The Patient agrees to:

Provide truthful, current, complete health, allergy, medication, and order information;

Confirm the medication, dose, route, and administration time before the visit;

Supply the medication and all necessary supplies as described above;

Disclose prior reactions, relevant medical conditions, and any change in instructions;

Contact the prescribing provider to resolve any discrepancy or treatment question;

Be present and ready at the scheduled time and provide a reasonably safe environment;

Keep children and animals safely controlled during the visit; and

Seek appropriate follow-up care and notify the prescribing provider of concerning symptoms.

6 Time Sensitive Medication

For a trigger injection or another time-sensitive dose, the Patient is responsible for providing the exact provider-ordered administration time and having the correct medication, order, and supplies ready before the Nurse arrives. The Nurse will make reasonable efforts to administer the dose at the stated time but does not determine whether a late or missed dose should be given. If delay or uncertainty occurs, the Patient must contact the prescribing provider immediately.

7 Consent and Risks

The Patient voluntarily consents to the limited nursing services described in this Agreement. Risks of medication preparation and injection may include pain, bruising, bleeding, redness, swelling, infection, dizziness or fainting, allergic reaction, medication side effects, and other medication-specific risks. The prescribing provider is responsible for explaining the medication’s expected benefits, alternatives, risks, and potential complications. The Patient may refuse or stop the service at any time before administration.

8 Emergencies

Fertility Nurse Care LLC is not an emergency service. For difficulty breathing, severe allergic reaction, chest pain, loss of consciousness, severe bleeding, severe or rapidly worsening symptoms, or another possible emergency, call 911 or seek emergency medical care immediately. For non-emergency side effects or treatment concerns, contact the prescribing provider or fertility clinic.

9 Fees Cancellation and Safety

The Patient agrees to pay the fee disclosed at booking. Unless a different written policy was provided at booking, cancellation with less than 24 hours’ notice, a missed appointment, or inability to perform the visit because the Patient lacks the medication, supplies, or valid order may result in a $100 fee. A booked fee may also be nonrefundable to the extent stated at checkout.

The Nurse may end or decline a visit for unsafe conditions, threatening or inappropriate behavior, uncontrolled animals, illegal activity, nonpayment, inaccurate information, or a request outside the Nurse’s scope or the provider’s order.

10 Privacy and Communication

The Nurse may collect and maintain information reasonably necessary to schedule, provide, document, and bill for services. The Patient authorizes appointment-related communication by the phone number or email provided. Electronic communication may carry privacy risks and must not be used for emergencies. Fertility Nurse Care LLC will not routinely contact the Patient’s fertility provider unless separately authorized or required or permitted by law.

11 No Guarantee and Governing Terms

The Nurse does not guarantee a particular treatment or fertility outcome. Nothing in this Agreement waives any right or liability that cannot lawfully be waived. This Agreement is governed by New Jersey law. If any provision is unenforceable, the remaining provisions remain in effect. This Agreement and any written booking or cancellation terms constitute the parties’ agreement for the requested service and may be changed only in writing.

12 Patient Acknowledgment

☐ I understand that Geraldine Eslava, RN, is the sole nurse providing my service through Fertility Nurse Care LLC and acts independently from my physician, clinic, and pharmacy.

☐ I have an existing, current, valid order from an authorized prescriber for the medication to be administered, and I will provide reliable provider-issued documentation of that order.

☐ I will have the correct medication prescribed and dispensed for me, together with every necessary administration supply, on hand at the scheduled visit.

☐ I understand that the Nurse will not prescribe, change, interpret, or independently manage my fertility treatment.

☐ I understand that unclear or conflicting instructions, missing medication or supplies, or a safety concern may prevent administration.

☐ I understand the general risks of injections, that no fertility outcome is guaranteed, and that emergencies require 911 or emergency care.

☐ I have read this Agreement, had an opportunity to ask questions, and voluntarily consent to the services described.