Informed Consent For Donor 10279 Arizona


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10279 (Arizona) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Biotinidase Deficiency, Very Long Chain Acyl-CoA Dehydrogenase Deficiency, Adenosine Deaminase Deficiency and Megalencephalic Leukoencephalopathy with Subcortical Cysts.
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 Biotinidase Deficiency, Very Long Chain Acyl-CoA Dehydrogenase Deficiency, Adenosine Deaminase Deficiency and Megalencephalic Leukoencephalopathy with Subcortical Cysts. 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 Biotinidase Deficiency, Very Long Chain Acyl-CoA Dehydrogenase Deficiency, Adenosine Deaminase Deficiency and Megalencephalic Leukoencephalopathy with Subcortical Cysts.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 10279 (Arizona) that has tested positive as a carrier of Biotinidase Deficiency, Very Long Chain Acyl-CoA Dehydrogenase Deficiency, Adenosine Deaminase Deficiency and Megalencephalic Leukoencephalopathy with Subcortical Cysts, 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 10279 (Arizona) that has tested positive as a carrier of Biotinidase Deficiency, Very Long Chain Acyl-CoA Dehydrogenase Deficiency, Adenosine Deaminase Deficiency and Megalencephalic Leukoencephalopathy with Subcortical Cysts, 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: April 18, 2019

Signature Certificate
Document name: Informed Consent For Donor 10279 Arizona
Unique Document ID: 709bb75bec2bc6521b3f7ed7ccad60a9dc6e6725
Timestamp Audit
April 18, 2019 11:11 am PSTInformed Consent For Donor 10279 Arizona Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103