Informed Consent For Donor 12358 Percy


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12358 (Percy) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Primary Hyperoxaluria Type 1.
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 Primary Hyperoxaluria Type 1. 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 Primary Hyperoxaluria Type 1.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 12358 (Percy) that has tested positive as a carrier of Primary Hyperoxaluria Type 1, 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 12358 (Percy) that has tested positive as a carrier of Primary Hyperoxaluria Type 1, 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.
Partner or Spouse Name
(if applicable):

Leave this empty:

Signed by Seattle Sperm Bank
Signed On: May 9, 2019

Signature Certificate
Document name: Informed Consent For Donor 12358 Percy
Unique Document ID: 21c548e7a5880b5a06a5de7c2625b5aeffb84dce
Timestamp Audit
March 27, 2019 12:06 pm PSTInformed Consent For Donor 12358 Percy Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103