Victorian Numbered Regulations

ASSISTED REPRODUCTIVE TREATMENT REGULATIONS 2009 (SR NO 177 OF 2009) - SCHEDULE 2

SCHEDULE 2

Sch. 2

Regulation 7

CONSENT TO DONATION OF GAMETES OR EMBRYOS

Name(s) of donor(s):

Donation:

o     *sperm/*oocytes; or

o     embryos created from donors' sperm and oocytes

*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 using *my gametes/*our embryos may be carried out on a maximum of ( insert number not exceeding 10 ) women.

This consent lapses—

o     10 years from the date on which it is given;

OR

o     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.

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