Informed Consent For Donor 12298 Banks


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12298 (Banks) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Medium Chain Acyl-CoA Dehydrogenase Deficiency, Congenital Finnish Nephrosis and Nephrotic Syndrome, NPHS2-related.
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 Medium Chain Acyl-CoA Dehydrogenase Deficiency, Congenital Finnish Nephrosis and Nephrotic Syndrome, NPHS2-related. 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 Medium Chain Acyl-CoA Dehydrogenase Deficiency, Congenital Finnish Nephrosis and Nephrotic Syndrome, NPHS2-related.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 12298 (Banks) that has tested positive as a carrier of Medium Chain Acyl-CoA Dehydrogenase Deficiency, Congenital Finnish Nephrosis and Nephrotic Syndrome, NPHS2-related, 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 12298 (Banks) that has tested positive as a carrier of Medium Chain Acyl-CoA Dehydrogenase Deficiency, Congenital Finnish Nephrosis and Nephrotic Syndrome, NPHS2-related, 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: April 16, 2020

Signature Certificate
Document name: Informed Consent For Donor 12298 Banks
lock iconUnique Document ID: d8bc436599329fc32b956df17efd0d11d41fc5a4
Timestamp Audit
April 16, 2020 11:19 am PSTInformed Consent For Donor 12298 Banks Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177