Informed Consent For Donor 12635 Osric


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12635 (Osric) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Cerebrotendinous Xanthomatosis and Alpha Thalassemia, HBA1/HBA2-related. 
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 Cerebrotendinous Xanthomatosis and Alpha Thalassemia, HBA1/HBA2-related. 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 Cerebrotendinous Xanthomatosis and Alpha Thalassemia, HBA1/HBA2-related.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 12635 (Osric) that has tested positive as a carrier of Cerebrotendinous Xanthomatosis and Alpha Thalassemia, HBA1/HBA2-related, 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 12635 (Osric) that has tested positive as a carrier of Cerebrotendinous Xanthomatosis and Alpha Thalassemia, HBA1/HBA2-related, 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: July 26, 2021


Signature Certificate
Document name: Informed Consent For Donor 12635 Osric
lock iconUnique Document ID: 96d4212a122beab4b485b8139d9b0b36605945d1
Timestamp Audit
July 26, 2021 2:03 pm PDTInformed Consent For Donor 12635 Osric Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177