First Name:

Surname:

Identity Number:

Residential Address:

Contact No.:

Email Address:

2.1. My Marital status is:
—Please choose an option—MarriedUnmarriedCivil Union/De Facto Marriage

[group marital1]We have been together for: (years).[/group]

[group marital2]We were married on: (date).[/group]

[group marital3]We have been married for: (years).[/group]

[group marital4]Partners details are:[/group]

[group marital6]First Name:
[/group]

[group marital7]Surname:
[/group]

[group marital8]ID Number:
[/group]

[group marital9]Residential Address:
[/group]

[group marital10]Contact No.:
[/group]

[group marital11]Email Address:
[/group]

First Name:

Surname:

Identity Number:

Residential Address:

Contact No.:

Email Address:

* Note -Identity number can be a passport number

First Name:

Surname:

ID Number:

Residential Address:

Contact No:

Email Address:

Note -Identity number can be a passport number

3.1. The clinic that the embryos are stored at are:
3.1.1. [name of fertility clinic];

3.2. The doctor that previously treated the Donor is:

3.2.1. [name of doctor];

3.3. The patient/ folder number for the Donor is:

3.3.1. [clinic patient/ folder number];

3.4. Relationship to the Recipient parent/s:
BrotherSisterCousinFriendOther
If Other:

3.5. Does the Donor have any children born using embryos created in the same batch as the embryos that are to be
donated?
YesNo
3.5.3. Birth Dates:

3.5.4. Sex:

4.1. The total number of embryos being donated are: [# of embryos];

*Note: Fertility Law will contact the Clinic / Lab and ascertain the exact details of the embryos.

4.2. Is it the intention of the Donor to donate all / only some of the embryos in storage?

AllSome
Details of the embryos to be donated:

*Description to be used is – straw colour that they are stored on and embryo grading given by the lab at the
time of freezing.

4.3. The embryos were created using:
The oocytes (eggs) of the Donor and the sperm of the Donor’s Spouse;The oocytes (eggs) of the Donor and the sperm of a known sperm Donor:The oocytes (eggs) of a known egg Donor and the sperm of the Donor’s Spouse;The oocytes (eggs) of an anonymous egg Donor and the sperm of the Donor’s Spouse;

Details of the known sperm Donor:
Name:
Contact #:

Details of the known egg Donor:
Name:
Contact #:

5.1. The doctor treating the Recipient Parents is:
5.1.1. [name of doctor];

5.2. The fertility clinic that we are at is:
5.2.1. [name of fertility clinic];

5.3. We are hoping to have treatment on:
5.3.1 date of treatment;

*NOTE – in terms of the Regulations: Artificial Fertilisation of Persons, an embryo donor is not defined, but rather a ‘gamete donor’
is defined. This is because the law sees an embryo donation as a double gamete donation. Despite the below questions referring
to a ‘gamete donation’, this information is still relevant for the purposes of your embryo donation.

6.1. Is it the parties’ intention that the Donor be a ‘gamete donor’ as described in the Regulations: Artificial Fertilisation of
Persons, and that such donation is for the purpose of artificial fertilisation of Recipient Parent 1, and for the
consequences of those sections to apply? The consequences of the Regulations are:
6.1.1. that the Donor not to obtain any children and/or parental rights and responsibility for herself/
himself/themselves;
6.1.2. that Recipient Parent 1 and 2 become the legal parents of any child born as a result of the donation and are
therefore co-guardians and co-holders of all parental responsibilities and rights in respect of the child
YesNo, our intention is:

*NOTE – in terms of the Regulations: Artificial Fertilisation of Persons, a gamete donor is entitled to specify the number of
artificial fertilisations that his/her gametes are authorised to be used for. Although artificial fertilisation does not guarantee a
successful pregnancy and/or live birth, it is easier to equate the number of children that the donor consents to, rather than
the number of artificial fertilisations.

6.2. The Donor consents to as many artificial fertilisations, being performed, as are necessary for Parent 1 to conceive the
below selected number of children being born as a result of his/her donation:

OneTwoThreeFourFiveThe Donor has no objection to the maximum number of 6 (six) children being conceived as a result of his/her gamete donation

*NOTE – The parties are required to be psychologically screened. The treating doctor/ clinic will obtain confirmation from a
psychologist who specialises in fertility related therapy, that we can proceed with the agreement.

7.1. I/We have seen a psychologist:
NoYes
7.1.2.1. [name of psychologist]
7.1.2.1. [contact details]

8.1. I/We understand that we will be required to pay for:

8.1.1. all medical costs associated with the artificial fertilisation
8.1.2. all legal costs, which costs are contained in the invoice provided to us by Fertility Law

9.1. Identity Book of all the parties
9.2. Passport of all the parties (if RSA identity document is not available)
9.3. Proof of Address of all the parties
9.4. Marriage certificate of all parties (if applicable)