Home Page	Contents    Membership    About Cryonics     FAQ     Links     News

This statement of perfusion preference has been made by CI Member ______________________________ currently residing at

____________________________________________________________ (hereinafter referred to as the "Patient")

and the CRYONICS INSTITUTE, a Michigan nonprofit corporation (hereinafter "CI").

Cryonics Institute perfusion is primarily concerned with vitrifying (eliminating ice from) the brain. In addition to the head perfusion, prospective patients (CI Members) can choose whether or not they wish to have their body perfused with a solution which may reduce, but cannot eliminate ice [choose ONLY ONE of (1) to (3) by initialing your choice]:

(1) ______ (initials) I, the Patient, would like to have my body perfused.

(2) ______ (initials) I, the Patient, I would NOT like to have my body perfused.

OR

(3) ______ (initials) I, the Patient, choose that CI is to use it's own discretion to decide whether or not to perfuse my body. The current standard of care is to not perfuse the body based on evidence that doing so might compromise the quality of the brain preservation, although it is recognize that this situation may change in the future with improved technology. ((3) is the default choice in the absence of an explicit selection of the first two choices.)

PATIENT (CI MEMBER) ___________________________________________________
                                                 (PRINTED NAME)

PATIENT (CI MEMBER) ________________________________ Dated _____________
                                                 (SIGNATURE)