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 MarriageLife PartnerCustomary 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 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

*NOTE – the identity of the Donor’s spouse is requested in order to ascertain whether he/she is at least aware of the Donor’s
pending donation. It is not a legal requirement, or a requirement for the procedure, that the Donor’s spouse consent to the
process. However, it is advisable that their consent is obtained. They will be requested to depose to an affidavit confirming
that they are aware of the process and have no objection to the Donor performing his/her donation

3.1. Relationship to the Recipient parent/s:
—Please choose an option—BrotherSisterCousinFriendOther
If Other:

4.1. The doctor treating the Recipient Parents is:
4.1.1.[name of doctor];

4.2. The fertility clinic that we are at is:
4.2.1.[name of fertility clinic];

4.3. We are hoping to have treatment on:
4.3.1 date of treatment;

5.1. 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, which are:
5.1.1. that the Donor not to obtain any children and/or parental rights and responsibility for herself/
himself/themselves;
5.1.2. 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
—Please choose an option—YesNo

5.2. The Donor will be donating:
—Please choose an option—SpermOocytes (Eggs)

*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.

5.3. 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:

—Please choose an option—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.

6.1. I/We have seen a psychologist:
—Please choose an option—NoYes– the details of who we have seen are, and I/we consent to Fertility Law contacting the psychologist to ascertain the outcome of our session/s:

6.1.2.1. [name of psychologist]
6.1.2.1. [contact details]

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

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

8.1. Identity Book of all the parties
8.2. Passport of all the parties (if RSA identity document is not available)
8.3. Proof of Address of all the parties
8.4. Marriage certificate of all parties (if applicable)