Informed Consent For Donor 10381 Bravo


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10381 (Bravo) 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 10381 (Bravo) 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 10381 (Bravo) 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.
Partner or Spouse Name
(if applicable):

Leave this empty:

Signature arrow

Signed by Seattle Sperm Bank
Signed On: May 6, 2020

Signature Certificate
Document name: Informed Consent For Donor 10381 Bravo
lock iconUnique Document ID: c8e2cc4e2fcc035b36fc41c8674cf3c6b11cd6a7
Timestamp Audit
May 6, 2020 2:37 pm PSTInformed Consent For Donor 10381 Bravo Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177