Donor Name: ________________________________________                                     CPR No.: ________________________________________

Evaluation

This donor assessment is based on a questionnaire, a personal interview, a physical examination, and legally required blood tests conducted to determine whether the sperm donor may be used in accordance with Danish legislation.

The donor has been informed that, as a known sperm donor (non-anonymous) in Denmark, and under Danish law, he is considered the father of the child unless the recipient woman is in a relationship with either a man or a woman who is to be the child's co-parent. In that case, parenthood/co-parenthood should be established before the commencement of treatment using Form No. 9 issued by the Danish Agency of Family Law (Familieretshuset).

The known sperm donor may request the clinic at any time to destroy any unused sperm. Furthermore, he must provide his consent each time sperm or embryos/blastocysts fertilized with his sperm are thawed.

We have discussed the following with the donor:

General health, use of medication, high-risk sexual behavior, any children and their health, hereditary diseases in the immediate family, and infectious diseases. However, we can never guarantee that the donor does not carry hereditary diseases.

Additional comments (if any):

Conclusion

Based on the questionnaire, the donor evaluation, and relevant tests, we assess that the donor is suitable to act as a known sperm donor.

The donor will provide his sperm donation to the Sperm Bank at the Department of Growth and Reproduction, Rigshospitalet, and will be screened for syphilis, chlamydia, gonorrhea, HIV, hepatitis B, and hepatitis C. The donor has been informed that all test results must be negative before the Fertility Clinic at Rigshospitalet can accept the donation.

The above evaluation has been read and approved by the donor.

The donor, the recipient, and the Fertility Clinic at Rigshospitalet are entitled to retain a copy of this evaluation, including information regarding the donor’s and recipient’s CPR numbers. The recipient will be asked to sign this document, thereby confirming that the couple approves of and wishes to receive sperm from the known donor.

Recipient

Woman’s Name: ________________________________________                             CPR No.: ________________________________________

Woman’s Signature: ____________________________________                            Date: ___________________

Partner’s Name: ________________________________________                                   CPR No.: ________________________________________

Partner’s Signature: ____________________________________                               Date: ___________________

Date and Signature of Healthcare Professional, Fertility Clinic, Rigshospitalet: