Scribd
Upload
63 views3 pages

Pricing Format

The Luma Fertility Financial Counselling Form outlines the details of IVF treatment, including package costs, inclusions, and exclusions. It specifies payment terms, refund policies, and terms & conditions regarding medical eligibility, treatment consent, success rates, confidentiality, legal parentage, and embryo storage. Patients must comply with medical instructions and may face treatment discontinuation under certain circumstances.

Uploaded by

chetna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
63 views3 pages

Pricing Format

The Luma Fertility Financial Counselling Form outlines the details of IVF treatment, including package costs, inclusions, and exclusions. It specifies payment terms, refund policies, and terms & conditions regarding medical eligibility, treatment consent, success rates, confidentiality, legal parentage, and embryo storage. Patients must comply with medical instructions and may face treatment discontinuation under certain circumstances.

Uploaded by

chetna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Luma Fertility

Financial Counselling Form

Name of Patient: Name of Husband: .

Name of Consultant Doctor: MRN: .

LMP: .

Type of Treatment advised: .

Package cost: ,

Package Inclusions:

 Pre OPU
 Doctor Consultation during stimulations
 Stimulation injections
 Follow up Ultrasound during Stimulation
 Pre OPU Prep

 OPU
 OPU (Ovum Pickup) under GA (Anesthesia)
 OT Charges
 Bed & Day Care Charges
 Clinical Charges- Surgeon, Anesthetist, nursing team, Care Navigator, Duty Doctor &
administrative Charges.
 RFID Card Charges

 IVF Lab & Embryo culture & Transfer


 IVF Lab Charges
 ICSI
 Embryologist Charges
 Fresh Embryo Transfer
 First BHCG Blood test & followed with Consultation
Package Exclusions:
 Scans & Consults
 OT Consumables at Actuals
 IVF Injections
 Embryo freezing of 2 cryotops for 6 months : Rs. 40000/-
 Additional Cryotop for every additional cryotop: Rs. 10000/-
 Frozen Embryo Transfer (2nd transfer) including thawing charges Rs. 50000/-
 Blastocyst Culture charges: Rs. 25,000/-
 Semen freezing for 1 month: Rs. 3000/-
 Any emergency procedures/ Lab tests/ drugs (if required & not included above)
 Additional Injection doses (Beyond 10 days or dose changes in between stimulation)

Payment Terms: (EMI Options AVAILABLE)


***Upon start of stimulation:** 50% of the total package amount is due.
***Day 5 of stimulation:** An additional 25% of the package amount is due.
***Balance payment:** The remaining 25% should be completed before the Ovum Pickup procedure.

Refund Policy
Terms & Conditions of IVF Treatment
A. Medical Eligibility
 IVF treatment is subject to clinical assessment by a fertility specialist.
 Luma Fertility reserves the right to decline or delay treatment based on medical, psychological,
or ethical considerations.
B. Treatment Consent
 Patients must sign the IVF Consent Form and agree to comply with medical instructions and
appointments.
 Both partners (if applicable) must sign consents regarding use and storage of embryos, eggs, or
sperm.
C. Success Rates
 IVF does not guarantee a pregnancy or live birth. Clinical success varies based on individual
factors.
D. Confidentiality
 All personal and medical information is protected under privacy laws.
 Data may be used anonymously for clinical audit or research (with patient consent).
E. Legal Parentage and Third-Party Involvement
 Patients must disclose if donor gametes or surrogacy are being used and may be required to
provide legal agreements.
F. Embryo/Gamete Storage
 Storage is available for embryos, sperm, or oocytes for up to 10 years (or as per legal
regulations).
 Annual storage fees apply. Failure to pay may result in disposal after due notice.
G. Discontinuation of Treatment
 Luma Fertility may pause or cease treatment in cases of non-compliance, aggressive behaviour,
or health concerns.

You might also like