Informed Consent For Donor 12361 Baker


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12361 (Baker) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Smith-Lemli-Opitz Syndrome.
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 Smith-Lemli-Opitz Syndrome. 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 Smith-Lemli-Opitz Syndrome.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 12361 (Baker) that has tested positive as a carrier of Smith-Lemli-Opitz Syndrome, 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 12361 (Baker) that has tested positive as a carrier of Smith-Lemli-Opitz Syndrome, 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 23, 2019

Signature Certificate
Document name: Informed Consent For Donor 12361 Baker
Unique Document ID: a18f3444d1148d146dc16196e3c3fdbfeadaa020
Timestamp Audit
May 23, 2019 10:40 am PSTInformed Consent For Donor 12361 Baker Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.103