Informed Consent For Donor 12348 Lloyd


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12348 (Lloyd) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of PEX1-related Zellweger Syndrome Spectrum.
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 PEX1-related Zellweger Syndrome Spectrum. 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 PEX1-related Zellweger Syndrome Spectrum.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 12348 (Lloyd) that has tested positive as a carrier of PEX1-related Zellweger Syndrome Spectrum, 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 12348 (Lloyd) that has tested positive as a carrier of PEX1-related Zellweger Syndrome Spectrum, 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: May 18, 2020

Signature Certificate
Document name: Informed Consent For Donor 12348 Lloyd
lock iconUnique Document ID: 577b9bbac50ce42248a995761fe008709c3b6567
Timestamp Audit
January 15, 2020 1:29 pm PDTInformed Consent For Donor 12348 Lloyd Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177