Victorian Numbered Regulations

ASSISTED REPRODUCTIVE TREATMENT REGULATIONS 2019 (SR NO 115 OF 2019) - SCHEDULE 1

Schedule 1—Consent to carrying out a treatment procedure

Regulation 6

Part A—Consent of woman who will undergo treatment procedure

I, [ name of woman who will undergo treatment procedure ]
of [ address ] consent to the following treatment procedure being carried out on me—

o     artificial insemination;

o     assisted reproductive treatment.

Signed:

Name: [ print name ]

Date:

*Part B—Consent of partner of woman who will undergo treatment procedure

I, [ name of partner of woman who will undergo treatment procedure ]
of [ address ] consent to the following treatment procedure being carried out on [ name of woman who will undergo treatment procedure ]—

o     artificial insemination;

o     assisted reproductive treatment.

Signed:

Name: [ print name ]

Date:

Notes:

1.     PART B must be completed if the woman consenting to the treatment procedure has a partner as defined in section 3 of the Act.

"partner", in relation to a person, means—

(a)     the person's spouse (other than a spouse from whom the person has separated); or

(b)     a person who lives with the first person as a couple on a genuine domestic basis, irrespective of gender.

2.     You or your partner are asked to please notify the registered ART provider or doctor carrying out the treatment procedure if you have separated.

3.     Consent may be withdrawn at any time before the treatment procedure or action consented to is carried out using the following procedure—

        (a)     the withdrawal of consent must be in writing;

        (b)     the person withdrawing the consent must give the withdrawal as soon as practicable to either—

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

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

4.     Section 38 of the Act makes it an offence to knowingly or recklessly give false or misleading information or omit to give material information on this consent form.

Part C—Statement by counsellor

I, [ name of counsellor who provided counselling under section 13 of the Assisted Reproductive Treatment Act 2008 ] of [ address ] * have/*have not sighted a criminal records check in relation to [ name of woman who will undergo treatment procedure ] *and [ name of partner of woman who will undergo treatment procedure ].

Signed:

Name: [ print name ]

Date:

*Delete if inapplicable.