Informed Consent For Donor 14084 Chao


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 14084 (Chao) 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, Argininemia and Alpha Thalassemia.
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 GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness, Argininemia and Alpha Thalassemia. 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 GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness, Argininemia and Alpha Thalassemia.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 14084 (Chao) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness, Argininemia and Alpha Thalassemia, 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 14084 (Chao) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness, Argininemia and Alpha Thalassemia, 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: March 31, 2021


Signature Certificate
Document name: Informed Consent For Donor 14084 Chao
lock iconUnique Document ID: 7541fa6acc1c2169d3a210086118f840cb5507be
Timestamp Audit
March 31, 2021 12:39 pm PDTInformed Consent For Donor 14084 Chao Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177