Informed Consent For Donor 10407 Hensley


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10407 (Hensley) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Hereditary Fructose Intolerance.
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 Hereditary Fructose Intolerance. 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 Hereditary Fructose Intolerance.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 10407 (Hensley) that has tested positive as a carrier of Hereditary Fructose Intolerance, 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 10407 (Hensley) that has tested positive as a carrier of Hereditary Fructose Intolerance, 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 genetic testing.
Partner or Spouse Name
(if applicable):

Leave this empty:

Signature arrow

Signed by Seattle Sperm Bank
Signed On: September 21, 2020

Signature Certificate
Document name: Informed Consent For Donor 10407 Hensley
lock iconUnique Document ID: 3d6f8a975e202315deae174a798213ef1dcdb502
Timestamp Audit
September 21, 2020 1:51 pm PSTInformed Consent For Donor 10407 Hensley Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177