Victorian Consolidated Regulations Victorian Consolidated RegulationsSchedule 2—Consent for use in Victoria of donor gametes or embryo produced from donor gametes donated in Victoria
Name(s) of donor(s):
Details of donation
□ *sperm/*oocytes; or
□ embryos produced from donors' sperm and oocytes
Consent for use in treatment procedures
*I/*We, [ name(s) of donor(s) ] of [ address(es) of donor(s) ] consent to the *gametes donated by me/*embryos donated by us being used in the following treatment procedures—
[ specify treatment procedures for which donor's gametes or donors' embryos may be used ]
Treatment procedures that result in children born using *my gametes/*our embryos may be carried out on a maximum of [ insert number not exceeding 10 ] women.
*Consent to obtain information
*I/*We, [ name and address of each donor signing the consent ] *have donated/*intend to donate *my gametes/*embryos formed from our gametes at [ insert name and address of registered ART provider or doctor ].
*I/*We consent to [ name of registered ART provider or doctor to whom consent is given ] contacting the registered ART provider or doctor named above to obtain information about use in treatment procedures of *gametes donated by me/*embryos donated by us.
This consent lapses—
□ 10 years from the date on which it is given;
OR
□ at the end of the following period: [ insert period not exceeding 10 years ].
Signed: [ signature of each donor ]
Name(s): [ print name(s) ]
Date:
*Delete if inapplicable.
Notes:
1. A person giving consent under section 16 of the Assisted Reproductive Treatment Act 2008 (the Act) must give the consent or cause the consent to be given to—
(a) if the donation is made—
(i) to a registered ART provider, a designated officer of the registered ART provider; or
(ii) to a person other than a registered ART provider, a doctor who is registered under the Health Practitioner Regulation National Law to practise in the medical profession (other than as a student); or
(b) if the donation is made outside Victoria, a person who is required to make a certification under section 36(3) of the Act.
See section 17(2) of the Act and regulation 8AA of the Assisted Reproductive Treatment Regulations 2019 .
2. A person who gives a consent under section 16 of the Act may withdraw it—
(a) in the case of donor gametes, at any time before the earliest of the following occurs—
(i) when the gametes are used in a treatment procedure;
(ii) if the gametes are earlier used to form an embryo, when the gametes are used to form the embryo; or
(b) in the case of consent given by a person who produced the gametes used to create the embryo, at any time before the embryo is used in a treatment procedure.
3. A withdrawal of consent must be in writing. A person withdrawing a consent must give the withdrawal or cause the withdrawal to be given as soon as practicable to—
(a) the registered ART provider or doctor to whom the consent was given; or
(b) the registered ART provider or doctor with whom the sperm, oocyte or embryo to which the consent relates is kept or stored; or
(c) if the donation is made outside Victoria, a person who is required to make a certification under section 36(3) of the Act.
See section 20(2) and (3) of the Act and regulation 8AB of the Assisted Reproductive Treatment Regulations 2019 .
4. We may contact a person you have named to obtain information about the use in treatment procedures of gametes or embryos you have donated. Section 29(1) of the Act prohibits a person carrying out a treatment procedure in Victoria if the person knows that the treatment procedure may result in more than 10 women having children who are genetic siblings.
5. Section 38 of the Act provides that it is an offence for a person to knowingly or recklessly give false or misleading information or omit to give material information in a consent.
In this Form, "treatment procedure" means—
(a) artificial insemination, other than self-insemination; or
(b) assisted reproductive treatment.
Sch. 2AA inserted by S.R. No. 141/2024 reg. 20.