Informed Consent For Donor 10212 Houston


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10212 (Houston) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Pendred Syndrome.
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 Pendred Syndrome. 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 JB2.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 10212 (Houston) that has tested positive as a carrier of JB2, 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 10212 (Houston) that has tested positive as a carrier of JB2, 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.
Partner or Spouse Name
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Signed by Seattle Sperm Bank
Signed On: December 6, 2018

Signature Certificate
Document name: Informed Consent For Donor 10212 Houston
Unique Document ID: 204d91a93c972943c363e16a461f01bbd70ab857
Timestamp Audit
December 6, 2018 1:30 pm PSTInformed Consent For Donor 10212 Houston Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.112