Informed Consent For Donor 10264 Swift


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10264 (Swift) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Cystic Fibrosis.
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 Cystic Fibrosis. 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 Cystic Fibrosis.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 10264 (Swift) that has tested positive as a carrier of Cystic Fibrosis, 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 10264 (Swift) that has tested positive as a carrier of Cystic Fibrosis, 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: June 30, 2021


Signature Certificate
Document name: Informed Consent For Donor 10264 Swift
lock iconUnique Document ID: 66382445dd54c6ce673a05e8579a071dd22c0ab7
Timestamp Audit
June 30, 2021 12:38 pm PDTInformed Consent For Donor 10264 Swift Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177