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AGREEMENT
Come now the
parties, ___________________ and ___________________, hereinafter
referred to as "donors," and ____________________ and
____________________, hereinafter referred to as "donees," and enter
into this Embryo Transfer Agreement as follows:
1) The donors had embryos cryopreserved which are
currently in the custody of ______(clinic where embryos are
stored)______________ and now desire to donate these embryos to the
donees.
2) Donors agree and understand that the embryos they
are donating will be used for the purpose of causing a pregnancy by
embryo donation transfer to the donees.
3) The donors agree to ship these embryos at the
time and in the manner that is agreeable to both clinics from:
(donor’s clinic name & address)
to:
(donee’s clinic name & address)
4) Donors request no funds from the donees, other
than reimbursement for the costs associated with storing the embryos
with _________________________, plus any costs associated with shipping
the cryopreserved embryos from ______________________________to
__________________________.
5) Donors agree to complete requested blood work,
genetic screening, and a family medical history form to be sent to
__(donee’s clinic)___________. Donors also agree to participate
in a telephone interview with a representative of ________(donee’s
clinic)______, if requested.
6) Donors agree to immediately report any
significant changes in the status of their health to _______(donee’s
clinic)___________
7) Donors agree to be available to the donees and
any children resulting from this embryo donation to answer questions
concerning the personal and family health history of either donor.
8) Donors agree to relinquish all
present and future rights in said embryos, or any derivations
therefrom, to Donees.
9) The embryos donated include: ____ embryos which were cryopreserved on __________________.
10) The parties
hereby acknowledge that this agreement shall be formed in the
Commonwealth of Virginia. This agreement is to be interpreted and
governed in accordance with Virginia law, including but not limited to,
Va. Code Ann. §§20-156-165. All parties consent to
personal jurisdiction in the federal and state courts of Virginia for
any action arising out of or related to this agreement.
We certify that we have read and fully understand the above consent statement.
______________________________ _____________ September _____, 2002
Donor Social Security
______________________________ _____________ September _____, 2002
Donor Social Security
______________________________ _____________ September _____, 2002
Donee Social Security
______________________________ _____________ September _____, 2002
Donee Social Security
State of: ___________________
County of: _________________
On this _____ day of _____________, 2002, _____(names of
donors)_____personally appeared before me, a Notary Public in and for
the jurisdiction aforesaid, and acknowledged the foregoing document to
be their act and desire the same to be recorded as such.
Witness my hand and seal the day and year aforesaid.
My commission expires: ____________________________
___________________________________
Notary Public
State of: ___________________
County of: _________________
On this _____ day of __________, 2002, _______(names of
donees)____________personally appeared before me, a Notary Public in
and for the jurisdiction aforesaid, and acknowledged the foregoing
document to be their act and desire the same to be recorded as
such.
Witness my hand and seal the day and year aforesaid.
My commission expires: ____________________________
___________________________________
Notary Public
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The Miracles Waiting, Inc. Team
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