Informed Consent For Donor 12587 Pepin


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12587 (Pepin) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Phenylalanine Hydroxylase Deficiency.
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 Phenylalanine Hydroxylase Deficiency. 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 Phenylalanine Hydroxylase Deficiency.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 12587 (Pepin) that has tested positive as a carrier of Phenylalanine Hydroxylase Deficiency, 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 12587(Pepin) that has tested positive as a carrier of Phenylalanine Hydroxylase Deficiency, 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:

Signature arrow

Signed by Seattle Sperm Bank
Signed On: March 11, 2021

Signature Certificate
Document name: Informed Consent For Donor 12587 Pepin
lock iconUnique Document ID: dd3f9824b0e3eea84e708c590c0f61331d93f952
Timestamp Audit
March 11, 2021 11:55 am PDTInformed Consent For Donor 12587 Pepin Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177