Informed Consent For Donor 12386 Gerold


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12386 (Gerold) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Hereditary Fructose Intolerance and Sulfate Transporter-related Osteochondrodysplasia.
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 Hereditary Fructose Intolerance and Sulfate Transporter-related Osteochondrodysplasia. 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 Hereditary Fructose Intolerance and Sulfate Transporter-related Osteochondrodysplasia.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 12386 (Gerold) that has tested positive as a carrier of Hereditary Fructose Intolerance and Sulfate Transporter-related Osteochondrodysplasia, 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 12386 (Gerold) that has tested positive as a carrier of Hereditary Fructose Intolerance and Sulfate Transporter-related Osteochondrodysplasia, 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: August 13, 2020

Signature Certificate
Document name: Informed Consent For Donor 12386 Gerold
lock iconUnique Document ID: 4fe045807352f0f4aa47a896c1b7ae398aac4bb8
Timestamp Audit
January 15, 2020 12:31 pm PSTInformed Consent For Donor 12386 Gerold Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177