Informed Consent For Donor 10458 Valens


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10458 (Valens) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Methylmalonic Aciduria and Homocystinuria, cbIC Type.
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 Methylmalonic Aciduria and Homocystinuria, cbIC Type. 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 Methylmalonic Aciduria and Homocystinuria, cbIC Type.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 10458 (Valens) that has tested positive as a carrier of Methylmalonic Aciduria and Homocystinuria, cbIC Type, 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 10458 (Valens) that has tested positive as a carrier of Methylmalonic Aciduria and Homocystinuria, cbIC Type, 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: June 15, 2021


Signature Certificate
Document name: Informed Consent For Donor 10458 Valens
lock iconUnique Document ID: 1b8b3c25fc9a606de308970a6990e4c15ede3b5c
Timestamp Audit
September 25, 2020 11:26 am PDTInformed Consent For Donor 10458 Valens Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177