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AGREEMENT
Come now the parties, __________________ and
_________________, hereinafter referred to as the “Donors”, and
__________________ and __________________, hereinafter referred to as
the “Donees”, enter into this Embryo Transfer Agreement as follows:
1. The Donors had embryos cryopreserved which are currently in the
custody of the Reproductive Technology facility at Swedish Medical
Center and now desire to donate these embryos to the Donees.
2. The 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 request no funds from the Donees, other than
reimbursement for the costs associated with storing the embryos with
Swedish Medical Center.
4. The Donors agree to complete requested blood work, genetic
screening, and a family medical history form. Donors also agree
to participate in a telephone interview with Swedish Medical Center, if
requested.
5. The Donors agree to immediately report any significant changes in the status of their health to Swedish Medical Center.
6. The Donors agree to be available to the Donees and any resulting
children from this embryo donation to answer questions concerning the
personal and family health history of either donor.
7. The Donors agree to relinquish all present and future rights to said embryos, or any derivations therefrom to Donees.
8. The embryos donated include:_____ embryos which were cryopreserved on ___________, 2003.
9. The parties hereby acknowledge that this agreement shall be formed
in the Commonwealth of Washington. This agreement is to be
interpreted and governed in accordance with Washington Law, including
but not limited to, Washington RCW 26.26.705. All parties consent
to personal jurisdiction in the federal and states courts of Washington
for any action arising out of, or related to this agreement.
We certify that we have read and fully understand the above consent statement.
__________________________ ________________ _____________
Donor
Social Security
# Date
__________________________ ________________ ____________
Donor
Social
Security # Date
State of Washington
County of: _______________
On this _______ day of __________, 2004,
___________________ and _________________ personally appear before me,
a Notary Public in and for the jurisdiction aforesaid, and acknowledge
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
We certify that we have read and fully understand the above consent statement.
________________________ ________________ ______________
Donee
Social Security
# Date
________________________ ________________ ______________
Donee
Social Security
# Date
State of Washington
County of : _____________
On this _______ day of _____________, 2004,
_____________________ and __________________ personally appear before
me, a Notary Public in and for the jurisdiction aforesaid, and
acknowledge 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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