Informed Consent For Donor 10116 Hardev


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10116 (Hardev) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Primary Carnitine Deficiency.
Patient is aware of the aforementioned exceptions and genetic disease risks associated with each.
Patient agrees to personally assume all risks associated with Patient’s use of semen samples donated by a Donor that has tested positive as a carrier of Primary Carnitine Deficiency. Patient hereby releases Seattle Sperm Bank and its current and former officers, directors, employees, attorneys, insurers, agents and representatives of any liability or responsibility whatsoever for any and all outcomes, whether currently known, suspected, unknown or unsuspected, arising out of Patient’s use of donor semen donated by Donor that has tested positive as a carrier of Primary Carnitine Deficiency.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 10116 (Hardev) that has tested positive as a carrier of Primary Carnitine Deficiency, and I have been offered genetic testing for this condition by Seattle Sperm Bank and I am choosing to DECLINE testing on myself for this condition.

I understand the risks associated with using donor semen donated by Donor 10116 (Hardev) that has tested positive as a carrier of Primary Carnitine Deficiency, and I have been offered genetic testing for this condition and have chosen to have myself screened for this condition, as facilitated by Seattle Sperm Bank through the use of Counsyl genetic testing.
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Signed by Seattle Sperm Bank
Signed On: May 23, 2019

Signature Certificate
Document name: Informed Consent For Donor 10116 Hardev
Unique Document ID: 7ea72e4fa948cab0d29b2ab6de07687ac572379e
Timestamp Audit
May 23, 2019 1:51 pm PDTInformed Consent For Donor 10116 Hardev Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103