Informed Consent For Donor 14225 Storm


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 14225 (Storm) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Congenital Adrenal Hyperplasia, CYP21A2-related, Niemann-Pick Disease, SMPD1-related and Fanconi Anemia Complementation Group A.
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 Congenital Adrenal Hyperplasia, CYP21A2-related, Niemann-Pick Disease, SMPD1-related and Fanconi Anemia Complementation Group A. 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 Congenital Adrenal Hyperplasia, CYP21A2-related, Niemann-Pick Disease, SMPD1-related and Fanconi Anemia Complementation Group A.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 14225 (Storm) that has tested positive as a carrier of Congenital Adrenal Hyperplasia, CYP21A2-related, Niemann-Pick Disease, SMPD1-related and Fanconi Anemia Complementation Group A, 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 14225 (Storm) that has tested positive as a carrier of Congenital Adrenal Hyperplasia, CYP21A2-related, Niemann-Pick Disease, SMPD1-related and Fanconi Anemia Complementation Group A, 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: January 14, 2022


Signature Certificate
Document name: Informed Consent For Donor 14225 Storm
lock iconUnique Document ID: 09a7b2d4a8799b81c13a7359452bd76c756c9230
Timestamp Audit
January 14, 2022 1:58 pm PSTInformed Consent For Donor 14225 Storm Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177