Form J - Agreement For Surrogacy
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4FORM - J
Agreement for Surrogacy
(See Rule 15.1)
I, ____________________________________ (the woman), with the consent
of
my
husband
(name),
of
____________________________________________
(address)
have
agreed
to
act
as
a
surrogate
mother
for
_______________________________________________________________
I had a full discussion with ____________________________________ of the
clinic on _______________________ in regard to the matter of my acting as a
surrogate mother for the child of the above couple.
I understand that the methods of treatment may include:
1.
Stimulation of the genetic mother for follicular recruitment.
2.
The recovery of one or more oocytes from the genetic mother by
ultrasound-guided oocyte recovery or by laparoscopy.
3.
The fertilization of the oocytes from the genetic mother with the sperm of
her husband or an anonymous donor.
4.
The
fertilization
of
a
donor
oocyte
by
the
sperm
of
the
husband/anonymous donor.
5.
The maintenance and storage by cryopreservation of the embryo resulting
from such fertilization until, in the view of the medical and scientific staff, it
is ready for transfer.
6.
Implantation of the embryo obtained through any of the above possibilities
into my uterus, after the necessary treatment if any.
I have been assured that the genetic mother and the genetic father have been
Screened for HIV and hepatitis B and C before oocyte recovery and found to be
seronegative for all these diseases. I have, however, been also informed that
there is a small risk of the mother or / and the father becoming seropositive for
HIV during the window period.
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