Informed Consent For Donor 12416 Reo


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12416 (Reo) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of EVC-related Ellis-van Creveld 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 EVC-related Ellis-van Creveld 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 EVC-related Ellis-van Creveld Syndrome.
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 12416 (Reo) that has tested positive as a carrier of EVC-related Ellis-van Creveld 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 12416 (Reo) that has tested positive as a carrier of EVC-related Ellis-van Creveld 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 18, 2020

Signature Certificate
Document name: Informed Consent For Donor 12416 Reo
lock iconUnique Document ID: 93ec51605670be4da3384a438916bc67fd1d1a1e
Timestamp Audit
February 26, 2020 12:17 pm PDTInformed Consent For Donor 12416 Reo Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177