Informed Consent For Donor 12296 Leon


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12296 (Leon) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of AMT-related Glycine Encepalopathy and Alpha Thalassemia.
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 AMT-related Glycine Encepalopathy and Alpha Thalassemia. 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 AMT-related Glycine Encepalopathy and Alpha Thalassemia.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 12296 (Leon) that has tested positive as a carrier of AMT-related Glycine Encepalopathy and Alpha Thalassemia, 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 12296 (Leon) that has tested positive as a carrier of AMT-related Glycine Encepalopathy and Alpha Thalassemia, 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: November 8, 2018

Signature Certificate
Document name: Informed Consent For Donor 12296 Leon
Unique Document ID: b0171e0ab40869545c73914c6a1b16de88e86af0
Timestamp Audit
November 8, 2018 8:50 am PSTInformed Consent For Donor 12296 Leon Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.112