Informed Consent For Donor 12643 Humboldt


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12643 (Humboldt) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Hereditary Fructose Intolerance, Multiple Sulfatase Deficiency and HFE-associated Hereditary Hemochromatosis.
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, Multiple Sulfatase Deficiency and HFE-associated Hereditary Hemochromatosis. 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, Multiple Sulfatase Deficiency and HFE-associated Hereditary Hemochromatosis.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 12643 (Humboldt) that has tested positive as a carrier of Hereditary Fructose Intolerance, Multiple Sulfatase Deficiency and HFE-associated Hereditary Hemochromatosis, 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 12643 (Humboldt) that has tested positive as a carrier of Hereditary Fructose Intolerance, Multiple Sulfatase Deficiency and HFE-associated Hereditary Hemochromatosis, 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: December 30, 2021


Signature Certificate
Document name: Informed Consent For Donor 12643 Humboldt
lock iconUnique Document ID: dbeaeb4eb7405232c524d4881bf2462d7bfc740c
Timestamp Audit
December 30, 2021 7:06 am PSTInformed Consent For Donor 12643 Humboldt Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 50.125.91.15