Egg Donor Consent Form

Egg Donor Consent Form
Personal Details
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient No.
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Marital Status
Occupation
Emergency Contact
Next of Kin
Additional Provisions For A Known Related Egg Donor
Special Acknowledgement — Known Related Donor

4. No Intended Parental or Custodial Role - I do not intend, solely by reason of providing my oocytes, to acquire custody, parental responsibility, guardianship, decision-making authority or a right to determine the upbringing of any resulting child. I understand that the legal position regarding parentage and parental responsibility is ultimately subject to applicable law and any competent court or authority.6. Inheritance and Estate Matters - I understand that my genetic relationship to a child conceived using my donated oocytes is separate from the intended parental and family relationship established by the parties. I do not intend, solely by reason of my egg donation, to create an entitlement to inheritance, succession, maintenance or other financial benefit for the resulting child from my estate, nor do I intend to acquire an inheritance or succession claim against the child's estate solely by reason of the donation. I understand that inheritance and succession rights may be governed by applicable law and that this consent form cannot override any mandatory legal rights. Where appropriate, I acknowledge that separate wills, estate-planning documents and legal advice may be required to give effect to the parties' intentions.7. Guardianship and Future Care - I understand that my status as a genetic donor does not mean that I will automatically become the child's guardian or assume responsibility for the child's care if the Intended Mother or another Intended Parent dies or becomes incapacitated. Any guardianship or alternative-care arrangements should be established separately by the Intended Parent(s) in accordance with applicable law.8. Relationship With the Child - I acknowledge that I may remain a member of the child's extended family because I am the Intended Mother's/Father's sister. I understand that I may therefore have a family relationship with the child in my capacity as an aunt or other family member. Such family contact does not, by itself, create an intended parental relationship or confer parental decision-making authority upon me.9. Future Contact and Boundaries - I understand that any future relationship or contact between me and a child conceived using my oocytes will take place within the context of our family relationship and shall be managed in a manner that respects the child's welfare and the role of the Intended Parent(s). I will not represent myself to the child as a parent or seek to assume a parental role solely because I am the genetic donor.10. Disclosure of Genetic Origins - I understand that the child may eventually become aware that my oocytes were used in their conception. I acknowledge that, because I am a close biological relative of the Intended Mother/Father, complete anonymity cannot reasonably be guaranteed. I understand that modern genetic testing may also independently reveal biological relationships. I acknowledge that decisions regarding disclosure of the child's genetic origins should be approached sensitively, responsibly and in a manner appropriate to the child's age, welfare and applicable law.15. Independent Psychological Counselling - I acknowledge that I have been given an opportunity to receive independent psychological or counselling support regarding the emotional and family implications of donating my oocytes to my sister. I understand that the pre-existing family relationship may create emotional pressures or expectations that would not ordinarily exist in an unrelated donation.19. Death or Incapacity of the Intended Mother/Father - I understand that the death or incapacity of the Intended Mother/Father does not, solely by reason of my genetic relationship to a resulting child, automatically make me the child's parent, guardian or primary caregiver. Any such arrangements should be determined through appropriate legal and estate-planning arrangements and in accordance with applicable law.24. Use, Storage and Disposition of Oocytes and Embryos - I understand that my donated oocytes may be used to create embryos in accordance with the applicable IVF treatment plan and consent documentation. I understand that appropriate separate consent is required regarding the storage, continued use, transfer, disposal or other permitted disposition of any resulting embryos or reproductive material.27. Confidentiality - I understand that my identity as a known related donor will be recorded in the relevant clinical and legal documentation. I understand that confidentiality will be maintained to the extent reasonably possible and permitted by law, but that absolute confidentiality cannot be guaranteed because of our existing family relationship and the possibility of future disclosure or genetic testing.32. Confirmation of Understanding - I confirm that I have read and understood these additional provisions applicable to me as a known related egg donor. I confirm that I have had sufficient opportunity to ask questions and obtain independent legal and psychological advice and that I understand the medical, genetic, emotional, family and potential legal implications of donating my oocytes to my biological sister/brother.
ACKNOWLEDGEMENT — KNOWN RELATED EGG DONOR

I, the undersigned Egg Donor, expressly acknowledge that I am the biological sister of the Intended Mother/Father and that I am participating as a known, related egg donor. I understand that any child conceived using my donated oocytes will be genetically related to me and that my role is limited to that of an egg donor and is not intended to create a parental, custodial, guardianship, financial or inheritance relationship with any resulting child, subject to applicable law.

I confirm that I have read, understood and had the opportunity to obtain independent legal and psychological advice regarding all of the Additional Provisions for Known Related Egg Donation set out above, including those concerning genetic relationship, intended parentage, future contact and family relationships, disclosure of genetic origins, medical and genetic information, confidentiality, financial responsibility, inheritance and estate matters, guardianship, death or incapacity, future use of embryos, family relationship changes and other matters addressed in this section.

I confirm that my decision to donate is made freely, voluntarily and without coercion or undue influence, and that I understand the medical, genetic, emotional, family and potential legal implications of donating my oocytes to my biological sister. I acknowledge that I have had the opportunity to ask questions, seek clarification and obtain independent advice before providing my consent.

By signing below, I confirm that the foregoing provisions accurately reflect my understanding and intentions in relation to my donation and that I consent to the donation and its use in accordance with this Consent Form, the applicable IVF treatment documentation and applicable law.
Name

First NameLast Name
Signature
Independent Witness Name

First NameLast Name
Witness Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical History and Consent Acknowledgements
Voluntary Participation
Medical Screening
Fertility Medication
Egg Retrieval
Future Fertility
Use of Donated Eggs
Donor Identity
Confidentiality
Legal Advice
Psychological Counselling
Declaration
Signatures and Date
Donor Signature
Name

First NameLast Name
Clinician/Nurse/Counsellor Signature
Name

First NameLast Name
Embryologist Signature
Name

First NameLast Name
Witness Signature
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Clinic Certification
Clinic Branch
Patient/Donor/Surrogate Name

First NameMiddle NameLast Name
Hospital Number
Procedure
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Certification Checkboxes
Clinic Representative Name

First NameMiddle NameLast Name
Clinic Representative Position
Clinic Representative Signature
Clinic Representative Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Treating Physician Name

First NameMiddle NameLast Name
Signature
Should be Empty:

Egg Donor Consent Form

Personal Details

Additional Provisions For A Known Related Egg Donor

Medical History and Consent Acknowledgements

Signatures and Date

Clinic Certification