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RELEASE OF INFORMATION
I/we, __________________
and _________________________, authorize Embryos Alive, Bonnie Bernard M.Ed.
and/or EA staff to obtain, review, disseminate and or discuss any information
related to adopting embryos with potential
donor parent/s, clinic/s staff, or others involved with the process of
adopting embryos for the purpose of transferring
embryo/s donated/adopted to us.
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
My/our
reproductive endocrinologist ______________________ of
________________________ may receive
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