Patient
A power of attorney for the number of embryos to be returned
I the undersigned,
Name ______________ surname____________________ ID No. _________________
I undergo IVF treatment with my partner in the IVF Herzliya Medical Center:
Name ______________ surname____________________ ID No. _________________
If I cannot be present at the time of embryo transfer stage, I hereby authorize my partner to
decide exclusively on the number of embryos to be transferred to her uterus and in
accordance with the recommendation of the attending physician.
The validity of the power of attorney is valid for one year from the date of signing or
canceling it, in a notice sent in writing and approved by the hospital.
___________________________
Signature
_________________
Date
Witness to the signing of the power of attorney
Name ______________ surname____________________ ID No. _________________