Fresh Sperm Insemination
Recipient Consent Form
I, ______, a woman 18 years of age and older, authorize midwife, Kelley Faulkner of New Life Midwifery, and her designated associates to inseminate me with fresh sperm obtained from a donor for the purpose of becoming pregnant. In signing this, I am verifying, as per the FDA regulations, that this donor is someone with whom I have been sexually intimate and, therefore, testing and screening are not requirement for insemination.
I understand that the use of fresh sperm is inherently more dangerous that the use of frozen sperm. Fresh is not quarantined as frozen is, and donors may not be screened for risk factors, therefore, my child or I could contract a disease from the donor. I understand and accept that the donor insemination procedure with fresh or frozen sperm carries with it the risk of sexually transmitted diseases including, but not limited to aids, gonorrhea, syphilis, herpes, Chlamydia, ureaplasma, mycoplasma, and cytomegalovirus.
As with many medical procedures, I understand that insemination, though performed with sterile equipment, may carry risk of infection, specifically infection of the reproductive organs. Furthermore, I acknowledge that those with allergy sensitivities to egg, saline or penicillin antibiotics should not engage in any insemination that may involve sperm media. I understand that I should inquire with the midwife performing my insemination about whether the procedure will involve sperm media if I am unsure, if I have an allergy to any of the above mentioned products, it is important that these be disclosed beforehand. I do hereby absolve, release, indemnify, protect and hold harmless New Life Midwifery, and it’s associates, from any and all liability for adverse effects, if I have not fully disclosed my known allergies or if I develop a reaction or infection resulting from insemination.
I understand that, if I develop any adverse side affects including severe and prolonged cramping, fever, abnormal heavy bleeding that is not menses, or difficulty breathing, I must immediately seek medical attention to ensure that the condition is promptly resolved.
I understand that there is no guarantee that insemination will result in pregnancy. I further understand that within the normal human population, a certain percentage (approximately 4%) of children are born with physical and/or mental defects, and that the occurrence of such defects is beyond the control of New Life Midwifery. I therefore understand and agree that New Life Midwifery and it's providers do not assume responsibility for the physical and mental characteristics of any child or children born as a result of donor insemination.
I understand that, within the normal population, approximately 20% of pregnancies, including those that result from insemination, result in miscarriage. I have been informed that the procedure of insemination may occasionally result in mild spotting and/or temporary cramping that should resolve within the day of the procedure.
I understand that obstetric complications may occur in any pregnancy. This agreement is, therefore, not a contract to cure, a warranty of treatment, nor a guarantee of conception. I do hereby absolve, release, indemnify, protect and hold harmless New Life Midwifery, and it’s associates, from any and all liability for the mental or physical nature of any child or children so conceived or born, and affirmative acts or acts of omission which may arise during the performance of this agreement.
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I further agree that I am assuming entire responsibility for any child or children conceived or born. I agree that I will not, nor will and child or children born, seek support for the child or children, or any other form of payment from the donor, midwives, physicians or associates affiliated with New Life Midwifery.
It is agreed that the nature of this agreement is such that it must remain confidential; therefore, I agree that a sole copy of this agreement may be retained in the above-named midwife's file and shall not be disclosed except with my express written permission, except as detailed in the New Life Midwifery Privacy Policy.
I hereby release Kelley Faulkner and her assistants from all liability for complications which may arise during or following my insemination, including during the course of my pregnancy, birth, or postpartum as a result of my decisions and my choice to receive insemination of donor sperm.
I acknowledge that I have thoroughly read and understood this document. I further acknowledge that I have had an opportunity to have any questions answered regarding the benefits and risks specific to insemination with fresh or frozen sperm.
Based upon an understanding of the above, Kelley Faulkner and I promise to uphold an agreement of trust and cooperation that will contribute toward my overall health and wellbeing.
I HAVE READ, AGREE TO, AND UNDERSTAND THE ABOVE STATED MATERIAL.
Client name: ______Signature: ______
Date: ______
New Life Midwifery | 19 W. Walnut Street, Milford, MA 01757 | 508-429-6663 phone | 508-452-0111 fax