Consent to Donate Sperm to Designated Recipient - Screening, Authorization, Storage, and Parental Rights

Oct 1, 2026

Sperm donation consent form defining the donor’s voluntary offer to donate sperm for reproductive purposes to a named recipient individual or couple. It specifies two authorization options covering limited reproductive use with discard of remaining vials, or unrestricted use with relinquishment of ownership rights. The form requires medical history, physical exam, semen analysis, and FDA-referenced blood and urine testing for infectious diseases. It also addresses storage decisions for frozen sperm and limits liability for equipment failure, and confirms the donor relinquishes parental rights and duties.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Parties and Recipient Information

Authorization of Donated Sperm

Screening Tests for Sperm Donor

Storage of Frozen Sperm

Parental Rights and Duties

1. Names of parties I, , of County, City of in the state of am over the age of twenty-one (21) years. I voluntarily offer to donate my sperm to the following designated recipient individual or couple for reproductive purpose. | Name of recipient individual | | Date ofBirth | | --- | --- | --- | | Name of intimate partner of recipient individual | | Date ofBirth | | Address | State | Zip Code | Home phone Cell phone Work phone 2. Nature of authorization (Check ONE appropriate box and initial next to that box) □ I give my consent and authorize the designated recipient individual or couple to use the donated sperm strictly for her/their reproductive use only. After the designated recipient individual or couple complete or terminate treatment to achieve a pregnancy or pregnancies, all remaining vials of donated sperm will be discarded and destroyed without further notice to me. □ I give my consent and authorize the designated recipient individual or couple to have unrestricted use of the donated sperm. I relinquish all rights of ownership including the right of decision-making regarding the use, transfer of ownership and other disposition of the donated sperm. I understand and accept that this may mean upon completion or termination of treatment to achieve a pregnancy or pregnancies by the designated recipient individual or couple, the remaining vials of sperm may be donated to other individual(s) for reproductive purpose, donated for research purpose such as laboratory quality control or scientific studies, or discarded and destroyed. 3. Screening tests for sperm donor For the purpose of determining whether I am an acceptable sperm donor, I consent to a detailed medical history, a physical examination, a semen analysis and laboratory testing of my blood and urine for drug use and sexually transmitted diseases as required by the Food and Drug Administration (FDA) under federal law (21 CFR 1271 Human Cells, Tissues, and Cellular and Tissue Based Products HCT/P) . These tests include testing for human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV), hepatitis B, hepatitis C, syphilis, gonorrhea, chlamydia, and cytomegalovirus (CMV) infection. To the best of my knowledge: (Check EACH box, initial next to each box and fill in the blank for any exception that applies) □ I am in good health; I have no communicable disease; and I do not now, nor have I ever suffered from any physical or mental illness, diagnosed with any medical disease or condition, mental impairment or disability, except as follows: ________________________________________________________________________ ________________________________________________________________________ □ I am not now, nor have I ever been afflicted with human immunodeficiency viruses (HIV), hepatitis C, hepatitis B, syphilis, gonorrhea, chlamydia, genital herpes, condyloma or any other venereal disease, except as follows: ________________________________________________________________________ ________________________________________________________________________ □ I am not now, nor have I ever engaged in behavior recognized to be risk factors for human immunodeficiency virus (HIV) infection. These include but not limited to blood transfusion prior to 1985, prostitution, intravenous drug use, sexual relationship with a partner or partner(s) known to be HIV infected or engaged in behavior generally recognized to be risk factors for HIV infection. □ I am not now, nor have I ever had alcoholism, drug addiction, or intravenous drug abuse, except as follows: ________________________________________________________________________ ________________________________________________________________________ □ None of my grandparents, parents, brothers, sisters, or children, if any, nor their lineal descendants, have ever been afflicted with emotional illness or any inherited mental or physical disabilities or disease, except a

FAQs

What authorization options does the donor choose for donated sperm use?

The donor checks either consent for strictly reproductive use with remaining vials discarded after treatment, or consent for unrestricted use with relinquishment of ownership and decision-making rights, including possible donation for other purposes or disposal.

What screening tests are required for a sperm donor?

The donor consents to a detailed medical history, physical exam, semen analysis, and laboratory testing of blood and urine for drug use and sexually transmitted diseases, including HIV, HTLV, hepatitis B and C, syphilis, gonorrhea, chlamydia, and CMV.

How is storage of frozen sperm handled and what liability limits apply?

If accepted, semen samples are processed and frozen, then either stored on site at the Family Fertility Center or shipped to another facility for storage arranged by the donor. The form limits liability for destruction or damage caused by equipment failure, utility failure, natural events, or similar acts of God.

Oct 1, 2026

Uploaded by Nguyễn Văn Học