Informed Consent For Donor 10287 Jameson


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10287 (Jameson) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Mucopolysaccharidosis Type I.
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 Mucopolysaccharidosis Type I. 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 Mucopolysaccharidosis Type I.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 10287 (Jameson) that has tested positive as a carrier of Mucopolysaccharidosis Type I, 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 10287 (Jameson) that has tested positive as a carrier of Mucopolysaccharidosis Type I, 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: September 17, 2019

Signature Certificate
Document name: Informed Consent For Donor 10287 Jameson
Unique Document ID: ef0d8b9dd022c10fb4656f9699848e7c39c13d7f
Timestamp Audit
September 17, 2019 7:37 am PSTInformed Consent For Donor 10287 Jameson Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103