[p.1 of Form (8)] SAMP Consent to Designated Donation of Sperm Part I DONOR S CONSENT 1. I (name of donor) (hereinafter (Surname, Given s) (ID No.) called the Donor ), DO HEREBY CONSENT to donating my sperm to the following couple (hereinafter called the Recipients ), (Surname, Given s) (ID No.) (husband s name), and (wife s name), (Surname, Given s) (ID No.) with the understanding that my sperm will be used for the treatment of the Recipients and that this consent cannot be revoked or varied once my sperm has been donated, subject to any written agreement to the contrary between the Donor and the Recipients. 2. I acknowledge that the nature and implications of my donation have been explained to me by and I have been given the opportunity to ask any question I wish. I have also been offered a suitable opportunity to take part in counselling with about the implications of the donation. 3. I understand that my sperm will be stored for a maximum period of 2 years from the date of freezing the sperm. If the aforesaid treatment of the Recipients cannot be successfully carried out within that period, or if before the expiry of the said maximum storage period, it becomes impossible for any reason whatsoever for the aforesaid treatment to be successfully carried out, or if excess sperm remains after the completion of the aforesaid treatment, I consent that the sperm obtained from me may be (please tick one) - [ ] disposed of in accordance with the Guidelines on disposal of gametes or embryos ( the Guidelines ) in the Code of Practice on Reproductive Technology and Embryo Research published from time to time by the Council on Human Reproductive Technology. [ ] donated anonymously for the treatment of other infertile couples, in which event my sperm would not be used to produce more than a total of 1/2/3* live birth events, including the event of the designated donation, if successful (failing which the Centre may dispose of the stored sperm in accordance with the Guidelines). [ ] donated for research (failing which the Centre may dispose of the stored sperm in accordance with the Guidelines). [ ] donated for quality control and/or training (failing which the Centre may dispose of the stored sperm in accordance with the Guidelines). 4.# I understand that the embryo(s) produced from the fertilization of my sperm will be used for the infertility treatment of the Recipients. If the aforesaid treatment cannot be successfully carried out, or if it becomes impossible for any reason whatsoever for the
[p.2 of Form (8)] aforesaid treatment to be successfully carried out, or if excess embryo(s) remain after the completion of the aforesaid treatment, I consent that the embryo(s) produced from the aforesaid fertilization may be handled in accordance with the Recipients instructions, as set out in para. 12 hereof. 5. I understand that under the Parent & Child Ordinance (Cap. 429), I shall not be the legal father of the child(ren) born from my donated sperm. I also agree never to seek to make any claim over such child(ren) under any circumstance whatsoever. 6. To the best of my knowledge and belief - (a) I am in good health and have no communicable disease or hereditary disorder, except as follows - (b) None of my relatives has ever suffered from any inheritable disease, except as follows - 7. For the purpose of determining whether I am suitable as a donor of sperm, I consent to undergoing such blood tests (including HIV test) and medical examinations as shall be prescribed by the Centre. 8. I acknowledge that the Information Sheets at Appendices X and XI of the Code of Practice on Reproductive Technology and Embryo Research have been read by me/explained to me*. I fully understand the contents of the Information Sheets and I agree that my personal data and information may be used for the purposes as set out therein.
[p.3 of Form (8)] Dated the day of (Month) (Year) Date of Birth (Donor s Signature) (dd/mm/yy) (Signature of Attending Doctor) (Signature of Witness) Position
[p.4 of Form (8)] Part II RECIPIENTS CONSENT 9. We (the Recipients), (husband s name), (Surname, Given s) (ID No.) and (wife s name), (Surname, Given s) (ID No.) of (address), being lawfully married and desirous of having a child, DO HEREBY CONSENT to receiving the sperm donated by (Surname, Given s) (ID No.) (the Donor) for infertility treatment. 10. We acknowledge that the nature and implications of the aforesaid treatment have been explained to us by and we have been given the opportunity to ask any question we wish. We have also been offered a suitable opportunity to take part in counselling with about the implications of the donation. 11. We fully understand and accept that - (a) the aforesaid treatment procedure may not result in a successful pregnancy; (b) the wife may not be able to carry the pregnancy to term; and (c) any child conceived or born as a result of the procedures may suffer from defect(s) of health or mental or physical impairment(s) as a result of congenital, hereditary or other reasons, similar to the situation of a normal pregnancy. 12.# We understand that the embryo(s) produced from the fertilization of the gametes of (please specify names of persons who are the origins of the gametes) will be used for the aforesaid infertility treatment and stored for such purpose for a maximum period of 2 years from the date of freezing the embryos, unless there are special circumstances justifying a longer storage period. If the aforesaid treatment cannot be successfully carried out within that period, or if, before the expiry of the said maximum storage period, it becomes impossible for any reason whatsoever for the aforesaid treatment to be successfully carried out, or if excess embryo(s) remain after completion of the aforesaid treatment, we consent that the embryo(s) produced from the aforesaid fertilization may be (please tick one) - [ ] disposed of in accordance with the Guidelines on disposal of gametes or embryos ( the Guidelines ) in the Code of Practice on Reproductive Technology and Embryo Research published from time to time by the Council on Human Reproductive Technology. [ ] donated anonymously for the treatment of other infertile couples, in which event the embryo(s) would not be used to produce more than a total of 1/2/3 * live birth events Note, including the event of the designated donation, if successful (failing which the Centre may dispose of the embryo(s) in accordance with the Guidelines).
[p.5 of Form (8)] [ ] donated for research (failing which the Centre may dispose of the embryo(s) in accordance with the Guidelines). [ ] donated for quality control and/or training (failing which the Centre may dispose of the embryo(s) in accordance with the Guidelines). 13. We understand that under the Parent & Child Ordinance (Cap. 429), we shall be the legal parents of the child(ren) born from the aforesaid treatment procedure. 14. We acknowledge that the Information Sheets at Appendices X and XI of the Code of Practice on Reproductive Technology and Embryo Research have been read by us/explained to us*. We fully understand the contents of the Information Sheets and we agree that our personal data and information may be used for the purposes as set out therein. Dated the day of (Month) (Year) (Husband s Signature) (Wife s Signature) Marriage Certificate No. (Signature of Attending Doctor) (Signature of Witness) Position * Delete whichever is inapplicable. # To be completed only if the embryo(s) were produced from the wife s egg(s) (oocytes). Note : If the Donor has indicated to donate surplus or unused sperm to other infertile couple, the limit of live birth event specified by the donor in para. 3 should also be considered for the case which the Recipients indicate to donate the surplus or unused embryos to other infertile couple. The total no. of live birth events produced by the excess sperm and embryos subsequently created should not be more than 3.