Informed Consent For Donor 12244 Knox


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12244 (Knox) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of D-bifunctional Protein Deficiency.
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 D-bifunctional Protein Deficiency. 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 D-bifunctional Protein Deficiency.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 12244 (Knox) that has tested positive as a carrier of D-bifunctional Protein Deficiency, 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 12244 (Knox) that has tested positive as a carrier of D-bifunctional Protein Deficiency, 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: July 31, 2018

Signature Certificate
Document name: Informed Consent For Donor 12244 Knox
Unique Document ID: 2e23d84688f6d5c37cea135b169eeb25e419bc03
Timestamp Audit
July 31, 2018 2:56 pm PSTInformed Consent For Donor 12244 Knox Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.112