Victorian Consolidated Regulations

ASSISTED REPRODUCTIVE TREATMENT REGULATIONS 2019 - SCHEDULE 2A

Schedule 2A—Notice of separation

Regulation 8A

I, [ name of person ]

of [* address OR see attached]

give notice that I have separated from my former partner

[ name of former partner ]

of [ address: if current address is unknown, include former address ]

on [ date of separation ].

Signed:

Name: [ print name ]

Date:

Notes:

1.     Consent to a treatment procedure given by a woman and her partner under section 10(1) of the Act is taken to be withdrawn on their separation if the gametes were produced by the partner of the woman who is to undergo the treatment procedure. As soon as practicable after their separation, the woman and her former partner must each give written notice of the separation or cause the written notice to be given—

        (a)     to the registered ART provider or doctor to whom consent was given; or

        (b)     to the registered ART provider or doctor with whom the sperm, oocyte or embryo to which the consent relates is kept or stored.

2.     Section 22 of the Act provides that a designated officer of a registered ART provider or a doctor carrying out artificial insemination other than on behalf of a registered ART provider must—

        (a)     obtain and keep the original of each notice of separation given to them; and

        (b)     ensure that a certified copy of each notice of separation is given to the person who gave the notice of separation and to their former partner.

3.     An address of each party is required in order for the registered ART provider or doctor receiving the notice of separation to confirm a person's identity. If a person does not wish to disclose their current address on a notice of separation due to a copy being provided to their former partner, they may provide their current address in a separate document. The separate document should be signed by the person, reference the notice of

separation and include the name of the person, the name of their former partner and the date that the person signed the notice of separation.

4.     If you provide the relevant ART provider or doctor with a notice of separation, you are not required to also provide a written withdrawal of consent under section 20 of the Act.

5.     Section 38 of the Act makes it an offence to knowingly or recklessly give false or misleading information or omit to give material information that is required to be given under the Act or to be included in a register, record or notice under the Act.

*Delete if inapplicable.