Informed Consent For Donor 14069 Horton


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 14069 (Horton) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Biotinidase 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 Biotinidase 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 Biotinidase Deficiency.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 14069 (Horton) that has tested positive as a carrier of Biotinidase 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 14069 (Horton) that has tested positive as a carrier of Biotinidase 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.
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Signed by Seattle Sperm Bank
Signed On: May 17, 2021

Signature Certificate
Document name: Informed Consent For Donor 14069 Horton
lock iconUnique Document ID: 8892a781c31810b55fb0898bca48fd2e7d5fc53f
Timestamp Audit
May 17, 2021 1:37 pm PDTInformed Consent For Donor 14069 Horton Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177