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I/we ___________________________ and _________________________
authorize , Inc., Embryos Alive or staff, the cryogenic storage bank staff or Reproductive Endocrinologist

or staff and any (circle one) prospective adoptive or donor parent/s  to obtain, review, discuss any information

and or documents regarding my embryos in order to have the embryo/s adopted.

Mrs. Bernard, the Cryogenic bank or storage facility and or staff, my Reproductive Endocrinologist

and their staff, and my/our Agency, Attorney, or Facilitator, and (circle one) donor or adoptive parent/s may

exchange any necessary information regarding my/our embryo/s.

This release is good until cancelled in writing.

Sincerely,