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E of Birth: Date: . . (Surname): . . Phone Number: Address: Post Code: and I (First Name) (Surname): (if applicable) Date of Birth: . . Phone Number: Address: Post Code: We declare that the embryos produced from our eggs and sperm on (OPU date) . . and currently in clinical cryostorage are now excess to our reproductive needs. Please let us know if you would like to discuss these options further with a counsellor or a scientist. Please tick the appropriate option Option A: We her.

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