The below mentioned parties, who has previously undergone IVF treatments and thereby obtained frozen, unfertilized eggs, hereby authorize you to thaw and fertilize for use in my treatment of infertility.  

Date: ___________________  
 
 
The woman’s full name (block letters):

_________________________________________________________________ 
 
 
The woman’s signature

_________________________________________________________________  
 
 
CPR. number: _________________________________ 
 
 

The signed copy needs to be returned to The Fertility Department no later than the day after receiving your appointment.  
 
The least complicated way is to access through ‘MinSundhedsplatform’ www.MinSundhedsplatform.dk 

MinSundhedsplatform is an easy and  secure communication between patient and hospital 
 
If we do not have a signed copy of this document the department will not be able to treat you