Informed Consent For Donor 12360 Newton


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12360 (Newton) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss.
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 GJB2-related DFNB1 Nonsyndromic Hearing Loss. 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 GJB2-related DFNB1 Nonsyndromic Hearing Loss.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 12360 (Newton) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss, 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 12360 (Newton) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss, 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: March 27, 2019

Signature Certificate
Document name: Informed Consent For Donor 12360 Newton
Unique Document ID: dfe15980225f886f3dcfcea230f1df4984cfbb74
Timestamp Audit
March 27, 2019 12:14 pm PDTInformed Consent For Donor 12360 Newton Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103