Name woman:	Name man:

National identity number:	National identity number:

See previous assisted reproduction agreement

Fertilised embryos of adequate quality that are not transferred will be frozen and stored until the woman turns 46 years old. We are aware that frozen embryos may only be used in attempts to make the wife/co-habiting partner conceive. If we were to divorce or separate during the storage term it will not be possible to use the frozen embryos. Surviving wife/co-habiting partner can use eggs that have been fertilized with the deceased's semen for assisted reproduction. It must be documented that it is the deceased's wish.

The confirmation must be signed by both parties, and must be submitted to the Unit for Assisted Reproduction in advance of the treatment. 1 week in advance at the latest.

Note! Fertilised eggs will not be thawed until this confirmation is received.

We confirm that we are married/cohabitants and have received information about the treatment.

We hereby consent to thawed fertilised eggs being transferred to the woman.

……………………………

Place/date

……………………………	…………………………

Woman	Man

For the department:	Attempt scheduled for week:…………… Signatures and dates checked against previous confirmations: Sign………………….	Date:………………………

The confirmation must be dated and signed by both parties and returned to the unit by eDialog or by post.

(If you decide to send us the confirmation by post, be aware that you have to send the letter at least 14 days in advance of the treatment).