Release of Physician and Semen

DONOR ARTIFICIAL INSEMINATION

We, ____________ and __________________ (names), husband and wife, of ___________ (address), stipulate that _______________ (name of treating physician), who will perform artificial insemination donor (AID) procedures on ___________ (name of wife), has advised them in the presence of each other that the artificial insemination process may result, despite all precautions in donor selection, in the birth of an abnormal child or children. We, ___________ and ___________ (names) , further stipulate that ___________ (name of treating physician) has advised them in the presence of each other as to the potential psychological implications that the birth of a child or children through the artificial insemination donor (AID) procedure may have on both their marital relationship and the child or children.

We, ____________ and __________________ (names), specifically release __________ (name of treating physician) and the donor or donors whose semen is finally selected for the artificial insemination of ___________ (name of wife) from any and all liability and responsibility of any nature whatsoever that may result from the birth of an infant or infants abnormal in any respect, and further specifically release ____________ (name of treating physician) and the donor or donors whose semen is finally selected for the artificial insemination of ________ (name of wife) from any and all liability and responsibility whatsoever for any psychological consequences that the procedure may have on the marital relationship of _________ (name of husband) and ____________ (name of wife). Such specific releases are not intended in any way to diminish the further releases, general and specific, given by ___________ and __________ in this instrument.

Dated: __________, at __________ (time).

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(Signatures)

Executed in the presence of:

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(Signatures of witnesses, with names and addresses indicated for each person)