Informed Consent For Donor 10289 Duy


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10289 (Duy) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Beta-sarcoglycanopathy.
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 Beta-sarcoglycanopathy. 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 Beta-sarcoglycanopathy.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 10289 (Duy) that has tested positive as a carrier of Beta-sarcoglycanopathy, 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 10289 (Duy) that has tested positive as a carrier of Beta-sarcoglycanopathy, 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
(if applicable):

Leave this empty:

Signed by Seattle Sperm Bank
Signed On: July 30, 2019

Signature Certificate
Document name: Informed Consent For Donor 10289 Duy
Unique Document ID: ec0bc620af4f6792340c0df793e7e5eee1ef187b
Timestamp Audit
July 30, 2019 12:43 pm PDTInformed Consent For Donor 10289 Duy Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103