Healthcare Egg Donor Agreement

HEALTHCARE EGG DONOR AGREEMENT

This Egg Donor Agreement (Agreement) is entered into between Donor Name: and Clinic/Program Name: on Date: . Intended Recipient(s) or Intended Parent(s):

1. PURPOSE AND SCOPE

The Donor agrees to undergo evaluation, ovarian stimulation, monitoring, egg retrieval and related procedures for the purpose of providing oocytes to the Intended Recipient(s) and/or Clinic for assisted reproductive use, subject to the terms, consents and limitations set forth below.

2. DEFINITIONS

For purposes of this Agreement, "Donor" means the individual identified above; "Clinic" means the medical provider or program indicated above; "Intended Recipient(s)" means the person(s) identified above who will receive or have custody of resulting embryos or offspring; "Oocytes" or "eggs" means mature human oocytes retrieved from Donor.

3. DONOR REPRESENTATIONS AND WARRANTIES

The Donor represents and warrants the following (initial each box to indicate agreement):

Donor is of legal age to consent to medical treatment and donation under applicable law and is not a minor.

Donor has read and understands the medical, legal, psychological and financial aspects of egg donation and consents voluntarily without coercion.

Donor has fully disclosed all medical, genetic and behavioral history to the Clinic and has not withheld information that would reasonably affect suitability to donate.

Donor will undergo required infectious disease testing and understands that a positive result may prevent use of donated oocytes.

4. MEDICAL SCREENING, PROCEDURE CONSENT AND RISKS

The Donor authorizes and consents to all medically indicated evaluations and procedures related to donation, including but not limited to: blood testing, genetic screening, psychological evaluation, ovarian stimulation with hormone injections, transvaginal ultrasounds, anesthesia and transvaginal oocyte retrieval. The Donor acknowledges that the Clinic has explained the nature of these procedures and the reasonably foreseeable risks, which include but are not limited to: hemorrhage, infection, ovarian hyperstimulation syndrome (OHSS) which can be severe, anesthesia complications, damage to pelvic organs, thromboembolic events, and the possibility of hospitalization or long-term medical care.

The Donor understands and accepts that there are no guaranteed outcomes for fertility treatments and that donation may have unknown long-term risks. The Donor consents to treatment by qualified personnel and to receiving anesthesia if required.

Donor initials to confirm informed consent:

5. MEDICAL HISTORY & PATIENT INFORMATION

INSURANCE AND COVERAGE

6. MEDICAL HISTORY

7. TESTING, GENETIC SCREENING AND USE OF MATERIAL

The Donor consents to necessary laboratory testing, including but not limited to infectious disease screening (HIV, hepatitis, syphilis), genetic carrier screening, karyotyping where indicated, and any pregnancy testing required by the Clinic. Donor acknowledges that test results may affect eligibility to complete donation.

Disposition of donated oocytes will be governed by the Clinic's written directives and the consent of the Intended Recipient(s). Select permitted uses (check all that apply):

For creation of embryos for use by Intended Recipient(s)

Cryopreservation/storage for future use

Use for research only (no reproductive use)

Discard in accordance with Clinic policy if not used

8. CONFIDENTIALITY, ANONYMITY AND CONTACT

The Clinic will maintain medical records in accordance with applicable privacy law. The Donor chooses (select one):

Anonymous donation (no identifying information released to Intended Recipient(s) unless required by law)

Open-identity donation (Donor consents to release of identifying information to Intended Recipient(s))

Donor further consents to limited release of medical information to the Intended Recipient(s) as required for medical care of resulting offspring and authorizes contact as follows:

9. COMPENSATION, EXPENSES AND TAXES

Donor compensation and reimbursement terms are as follows. Compensation is not contingent upon the success of any fertility treatment unless otherwise explicitly agreed below.

Travel, lodging and other reasonable expenses will be reimbursed as follows:

Tax treatment: Donor understands and agrees that tax reporting and withholding obligations, if any, are the Donor's responsibility unless otherwise provided in writing by the payor. Donor will provide tax documentation as reasonably required.

10. RELEASE, INDEMNITY AND LIMITATION OF LIABILITY

To the fullest extent permitted by law, the Donor releases and discharges the Clinic, its physicians, staff, contractors, and the Intended Recipient(s) from liability for ordinary negligence in connection with the screening, treatment and donation processes, except for gross negligence or willful misconduct. The Donor agrees to indemnify and hold harmless the Clinic and Intended Recipient(s) from claims arising from Donor's false statements, omissions or breach of this Agreement.

11. HIPAA AUTHORIZATION AND RELEASE OF MEDICAL RECORDS

The Donor hereby authorizes the Clinic and its agents to disclose protected health information and test results related to donation to the Intended Recipient(s), their medical providers and legal representatives as necessary for medical care and treatment decisions, legal compliance and disposition of donated oocytes. This authorization expires on:

12. TERMINATION; WITHDRAWAL

The Donor may withdraw consent at any time prior to the administration of anesthesia for egg retrieval. Withdrawal does not relieve the Donor from obligations reasonably incurred prior to withdrawal. If the Donor withdraws after commencement of procedures or medications, compensation and expense reimbursement will be handled as described in Section 9 and as required by applicable law.

13. GOVERNING LAW; DISPUTE RESOLUTION

This Agreement shall be governed by the laws of the state or jurisdiction where the Clinic is located. Any dispute relating to this Agreement will be resolved by the procedures selected below:

Court litigation

Binding arbitration

14. MISCELLANEOUS

This Agreement constitutes the entire understanding between the parties regarding egg donation and supersedes all prior agreements and understandings. Any amendment must be in writing and signed by the Donor and an authorized representative of the Clinic. If any provision is held invalid, the remainder will remain in full force and effect.

15. ACKNOWLEDGMENTS

By signing below, the Donor certifies under penalty of perjury that the information provided in this Agreement and the attached medical history is true and complete to the best of Donor's knowledge, that the Donor has had the opportunity to ask questions and consult advisors, and that Donor voluntarily consents to the procedures described herein.

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