Informed Consent For Donor 14120 Cairo


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 14120 (Cairo) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Cystic Fibrosis and Autosomal Recessive Polycystic Kidney Disease, PKHD1-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 Cystic Fibrosis and Autosomal Recessive Polycystic Kidney Disease, PKHD1-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 Cystic Fibrosis and Autosomal Recessive Polycystic Kidney Disease, PKHD1-related.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 14120 (Cairo) that has tested positive as a carrier of Cystic Fibrosis and Autosomal Recessive Polycystic Kidney Disease, PKHD1-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 14120 (Cairo) that has tested positive as a carrier of Cystic Fibrosis and Autosomal Recessive Polycystic Kidney Disease, PKHD1-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.
Partner or Spouse Name
(if applicable):

Leave this empty:

Signature arrow

Signed by Seattle Sperm Bank
Signed On: October 13, 2021


Signature Certificate
Document name: Informed Consent For Donor 14120 Cairo
lock iconUnique Document ID: 0d18a1460d60fc870c3f05d9dc5bf45263e5b9ba
Timestamp Audit
October 13, 2021 9:29 am PDTInformed Consent For Donor 14120 Cairo Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177