Informed Consent For Donor 14068 Arbor


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 14068 (Arbor) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Congenital Adrenal Hyperplasia, CYP21A2-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 JB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Congenital Adrenal Hyperplasia, CYP21A2-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 ofJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Congenital Adrenal Hyperplasia, CYP21A2-related.
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I understand the risks associated with using donor semen donated by Donor 14068 (Arbor) that has tested positive as a carrier of JB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Congenital Adrenal Hyperplasia, CYP21A2-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 14068 (Arbor) that has tested positive as a carrier of JB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Congenital Adrenal Hyperplasia, CYP21A2-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: October 13, 2021


Signature Certificate
Document name: Informed Consent For Donor 14068 Arbor
lock iconUnique Document ID: 298aad1b139bbd2e15beb06db8143ff28cd852b6
Timestamp Audit
October 13, 2021 9:13 am PDTInformed Consent For Donor 14068 Arbor Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177