Informed Consent For Donor 10305 Ren


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10305 (Ren) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Hypophosphatasia, Autosomal Recessive.
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 Hypophosphatasia, Autosomal Recessive. 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 Hypophosphatasia, Autosomal Recessive.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 10305 (Ren) that has tested positive as a carrier of Hypophosphatasia, Autosomal Recessive, 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 10305 (Ren) that has tested positive as a carrier of Hypophosphatasia, Autosomal Recessive, 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: December 5, 2019

Signature Certificate
Document name: Informed Consent For Donor 10305 Ren
Unique Document ID: c566b026d7fc00b28fc1e8ebc100292b5858b8df
Timestamp Audit
May 14, 2019 9:59 am PSTInformed Consent For Donor 10305 Ren Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103