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Release Of Physician & Semen
Donor Artificial Insemination
We, (names) and (names), husband and wife, of (address), stipulate that (name of treating physician), who will perform artificial insemination donor 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, (names) 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 procedure may have on both their marital relationship and the child or children.
We, (names) 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 (names) and (names) in this instrument.
Dated: (date), at (time).
Executed in the presence of:
*** If Required By State Law ***
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]