Embryo Donation
Pre-IVF
Planning Packet
Welcome to Embryos Alive,
the second oldest of only two embryo adoption agencies in the
United States.
You were
referred to our offices by your clinic prior to your invitro fertilization
procedure to plan for unforeseen circumstances
in the future. We hope your IVF
is successful and that you have your dreams fulfilled.
In the event you have
remaining embryo(s) placed in storage and something happens to you, we want to
make you
aware of embryo adoption and to remind you to request the FDA post May 25, 2005
donor testing. We also want to thank you for requesting information
about embryo donation and your
choice to give your embryo(s) a chance for life!
The documents contained in this Informational Packet will acquaint you
with the steps involved in the pre-IVF
planning process, so you can prepare for future unforeseen circumstances. (if
you would like these forms e-mailed please
contact us)
If you decide you would like to proceed further, please contact us at
513-793-1593 or
e-mail us at
EmbryosAlive@yahoo.com and visit us at www.EmbryosAlive.com.
Our staff is available to
answer additional questions as well as mediate and facilitate your embryo
adoption plan.
Thank you in advance for giving us the chance to be a part of this potential
life-giving decision. We are excited
and happy to help! Please feel free to contact us at any time.
Warmlyy,
Bonnie J. Bernard___
Bonnie J. Bernard, M.Ed.
Founder/Executive Director
Table of Contents
|
Welcome Letter |
2 |
|
Relinquishment In The Event of Death |
4 |
|
Relinquishment In The Event of Legal Incapacitation |
5 |
|
Relinquishment In The Event of Divorce |
6 |
|
Disclosure Statement/Contract |
7 |
|
Considerations |
8 |
|
Profile/Bio |
9 |
|
Release of Information |
10 |
|
Contact Information
|
11 |
EMBRYO RELINQUISHMENT IN THE EVENT OF DEATH 4
In the
event of both of our deaths,
We, the Donor parents of
certain frozen embryos, under an Embryo
Adoption Agreement entered into on or about _________________200__ (hereinafter
referred to as “the
Agreement”), do hereby relinquish and surrender all such embryos which have not
been previously thawed,
consisting of ____ ( ) frozen embryos, cryogenically stored at
_________________________, (name
of clinic) in ___________________________ (address of clinic) so the
embryo(s) may be adopted or
donated by Embryos Alive or its designee for the purpose of adoption and
implantation in an adoptive mother.
This relinquishment shall be subject to the additional terms and conditions of
the Agreement.
Any and all records including, but not limited to, profile, photographs,
embryology report(s), blood laboratory
testing and or results report(s), social or medical history of all donors,
letter(s) of eligibility, physicals,
and psychological evaluation(s) requested
by Embryos Alive or potential adopter clinic(s) may be released
to
Embryos
Alive staff or
its designee to
assist in the match and adoption of said embryo(s).
Either or both of us
shall have the right to rescind this relinquishment within three (3) days of the
date hereof,
by notifying Embryos Alive by telephone at (513) 518-7006 (between the hours of
8:30 a.m. and 5:00 p.m.
Eastern Standard Time) followed by confirmation in writing delivered to Embryos
Alive at 7741 Pfeiffer Road,
Cincinnati, Ohio 45242, by first-class U.S. mail.
Genetic Parents:
_________________________________ ______________________________
(Print Genetic or Donor Parent Name) (Print Genetic or Donor Parent Name)
State of ____________) State of _____ )
) ss ) ss
County of __________ ) County of ______ )
Subscribed and sworn before me on this ____ Subscribed and sworn before me on this___
day of ___________, 2008. day of ___________, 2008.
_________________________ _________________________
Notary Public Notary Public
My commission expires: ______ My commission expires: ________
Embryos Alive, LLC
By:________________________________________,
Founder/Executive Director
Bonnie J. Bernard, M.Ed., N.C.C.
State
of Ohio
County of Hamilton
Subscribed and sworn to before me, this day of , 2008.
)
) Notary Public
· Please maintain an executed copy of this document with your will.
EMBRYO RELINQUISHMENT IN THE EVENT OF LEGAL INCAPACITATION 5
In the
event both of us are legally incapacitated,
We, the Donor parents of
certain frozen embryos, under
an Embryo Adoption Agreement entered into on or about _________________2008
(hereinafter referred
to as “the Agreement”), do hereby relinquish and surrender all such embryos,
________ ( ) (months
or years) after we have been diagnosed as legally incapacitated, which have
not been previously thawed,
consisting of ____ ( ) frozen embryos, cryogenically stored at
_________________________, (name
of clinic) in _________________________________________ (address of
clinic) so the embryo(s) may
be adopted or donated by Embryos Alive or its designee for the purpose of
adoption and implantation in
an adoptive mother. This relinquishment shall be subject to the additional terms
and conditions of the Agreement.
By signing this
relinquishment, we forever terminate and surrender all of our parental rights to
those
embryos including any and all parental rights to children born as a result of
the implantation of embryos
in the adopting mother after ______ ( ) (months or years) of
diagnosis of legal incapacitation.
Any and
all records including, but not limited to, profile, photographs, embryology
report(s), blood laboratory
testing and or results report(s), social or medical history of all donors, and
psychological evaluation(s) requested
by Embryos Alive or potential adopter clinic(s) may be released to
Embryos
Alive staff or
its designee to
assist in the match and adoption of said embryo(s).
Either or both of us
shall have the right to rescind this relinquishment within three (3) days of the
date hereof,
by notifying Embryos Alive by telephone at (513) 518-7006 (between the hours of
8:30 a.m. and 5:00 p.m.
Eastern Standard Time) followed by confirmation in writing delivered to Embryos
Alive at 7741 Pfeiffer Road,
Cincinnati, Ohio 45242, by first-class U.S. mail.
Donor or Genetic Parent:
_________________________________ ______________________________
(Print Genetic or Donor Parent Name) (Print Genetic or Donor Parent Name)
State of ____________) State of _____ )
) ss ) ss
County of __________ ) County of ______ )
Subscribed and sworn before me on this ____ Subscribed and sworn before me on this___
day of ___________, 2008. day of ___________, 2008.
_________________________ _________________________
Notary Public Notary Public
My commission expires: ______ My commission expires: ________
Embryos Alive, LLC
By:________________________________________,
Bonnie J. Bernard, M.Ed., N.C.C.
Founder/Executive Director
State of Ohio
County of Hamilton
Subscribed and sworn to before me, this
day of , 2008.
______________
Notary
Public
·
Please maintain an executed copy
of this document with your will.
EMBRYO RELINQUISHMENT IN THE EVENT OF DIVORCE 6
In the event of divorce, I/We ___________________________ and_________________
______________relinquish our parental rights of any unused embryos after ___ years from the date the divorce was finalized to the embryo(s) cryogenically stored at ______________ ____________________________________ (name and address of clinic), so the embryo(s) may be matched for adoption or donated by Embryos Alive or its designee for the purpose of adoption for the purpose of adoption and implantation in an adoptive mother. This relinquishment shall be subject to the additional terms and conditions of the Agreement.
Any and all records including, but not limited to, profile, photographs,
embryology report(s), blood laboratory testing and or results report(s),
letter(s) of eligibility, phsyical, social
or medical history of all donors, and psychological evaluation(s) requested by
Embryos Alive or potential adopter clinic(s) may be released to
Embryos
Alive staff or
its designee to assist in the match and adoption of said embryo(s).
Either or both of us
shall have the right to rescind this relinquishment within three (3) days of the
date hereof, by notifying Embryos Alive by telephone at (513) 518-7006 (between
the hours of 8:30 a.m. and 5:00 p.m. Eastern Standard Time) followed by
confirmation in writing delivered to Embryos Alive at 7741 Pfeiffer Road,
Cincinnati, Ohio 45242, by first-class U.S. mail.
Genetic or Donor Parents:
_________________________________ ______________________________
(Print Genetic or Donor Parent Name) (Print Genetic or Donor Parent Name)
State of ____________) State of _____ )
) ss ) ss
County of __________ ) County of ______ )
Subscribed and sworn before me on this ____ Subscribed and sworn before me on this___
day of ___________, 2008. day of ___________, 2008.
_________________________ _________________________
Notary Public Notary Public
My commission expires: ______ My commission expires: ________
Embryos Alive, LLC
By:________________________________________,
Bonnie J. Bernard, M.Ed., N.C.C.
Founder/Executive Director
State
of Ohio
County of Hamilton
Subscribed and sworn to before me, this day of , 2008.
)
) Notary Public
· Please maintain an executed copy of this document with your will.
Disclosure Statement/Contract 7
We are aware that embryo adoption is an
emotional and challenging process. Sensitive issues may arise that require
discussion between parties.
We will come to our adoption specialist first to resolve any problems that may arise. We understand s/he will work with us to the best of his/her ability to resolve any issues or concerns.
Embryos Alive cannot guarantee a perfect resolution but will do everything within its power and control to resolve any issues in our favor.
In the event that Embryos Alive cannot resolve an issue to our satisfaction, we understand that the staff empathizes with us and will endeavor to help us manage a difficult situation.
Adoptive parent(s) or their clinic may review our lab work in order to determine the viability of proceeding with the process.
In the event I/we change our mind and decide not to proceed, we have 48 hours from the date we agree to a match of adoptive parent(s) to cancel in writing by certified mail sent to Embryos Alive 7741 Pfeiffer Road, Cincinnati, Ohio 45242-5020. Should donor(s) decide after the 48 hour period not to proceed, the donor(s) may be responsible for any costs incurred by adoptive parent(s) and Embryos Alive in pursuing this process.
_____________________________ _____________________________
Applicant Applicant
_____________________________ _____________________________
Date Date
Considerations 8
· National statistics indicate a 40% chance frozen embryos will thaw. Of those that thaw, there is a 50% chance they will attach to the lining. (Since 2006 and the vitrification process statistics are 75-95% chance of thaw).
· The adoptive couple may give birth to the sex of the child you had hoped for.
· Caution to the anonymous option: your children could go to college, meet, and marry.
· FDA and SART guidelines from May 2005 recommend that clinics obtain initial donor blood work, and STD testing again at three (3) months after IVF. Adopter clinics may or may not request this additional blood work, which is covered by insurance under infectious diseases. If not covered by insurance, adopters will be asked to pick up the cost.
· Cord Blood storage is an option for unforeseen possible illness of your child(ren) in the future.
· The time it takes to match your embryos varies. We must have the embryology report from your clinic, which can take days, weeks, or months to obtain.
· You, E.A., the adoptive parents(s), and potential little ones are pioneers. We have no idea what issues or emotions may arise in the future, but we all have the love and best interest in mind for each other, especially the little ones!
· We have a dedicated Yahoo support group for parents who donated and children who were born: EmbieDonorSupport-subscribe@yahoogroups.com.
Profile/Bio 9
Name(s):
_____________________________________________
A complete Profile/Bio contains the following information to assist E.A. with your match:
Female
Male
Donor Egg
Biological
Donor Sperm
Biological
e.g., open, agency liaison, closed/anonymous
Please e-mail jpg photos or mail
12. Any medical history
Type of family we would like to choose:
1. Open/Agency Liaison/Closed * see our website on pros and cons of each level
2. Preferred age of couple
3. Married, Singles, or Either
4. Surrogate as some women cannot carry a child ___ yes ___no
5. Can they already have children? (some have
adopted, step, or grown children)
how many? _____
6. Age range preferred:
7. In the event ____ or more ___ embryos
remain, we would like to have two
families adopt.
8. Would you consider a handicapped parent(s) please describe:
9. Additional details you would like to add:
Release of Information 10
I/we, ___________________________ and _________________________, authorize Embryos Alive, Bonnie Bernard M.Ed. and/or E.A. staff to obtain, review, disseminate, and/or discuss any information related to adopting embryos with potential adoptive parent(s), clinical staff(s), or others involved with the process of adopting embryo(s) for the purpose of transferring embryo(s) donated/adopted by us.
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
My/our cryo storage facility, reproductive endocrinologist or ______________________ may obtain, receive and review any and all information and/or documents regarding embryo(s) to be transferred to us from Embryos Alive, Bonnie Bernard, or a representative from Embryos Alive.
This release is good permanently from the date it is signed unless cancelled in writing.
Sincerely,
________________________ _____________________
Signature Date
________________________ _____________________
Signature Date
Contact Information
Embryos Alive staff or Bonnie Bernard M.Ed. Founder/Executive Director of Embryos Alive, may be reached in the following ways:
E-mail: embryosalive@yahoo.com or bb@cinci.rr.com
E-mails are answered days, evenings, weekends, and many holidays. If contacting after regular business hours, please allow 24 hours for a response.
Cell:
513-518-7006
Toll-Free
Cell: 513-793-1593
Office:
513-793-1593
Fax: 513-793-0052
Alternate
Fax: 727-489-2427
Mailing Address: 7741 Pfeiffer Road, Cincinnati, Ohio 45242-5020
Office Hours: Monday–Friday 9:30 a.m. to 4:30 p.m. (E.S.T.)
Web site: www.EmbryosAlive.com