Informed Consent For Donor 8552 Dawson


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 8552 (Dawson) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that an offspring of the donor is reported to have a clinical diagnosis of Pendred syndrome. Pendred syndrome is a disorder associated with hearing loss and goiter. Half of Pendred cases are recessively inherited and caused by mutations in the SLC26A4 gene. For the remaining cases, the cause is unknown. Donor 8552’s offspring with a clinical diagnosis of Pendred syndrome was not found to carry SLC26A4 mutations. Therefore, an inherited form of Pendred syndrome for this offspring has not been identified, but it cannot be ruled out.
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 an offspring with a clinical diagnosis of Pendred syndrome, a condition that can have autosomal recessive inheritance. 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 a Donor that has an offspring with a clinical diagnosis of Pendred syndrome.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 8552 (Dawson) who has an offspring with a clinical diagnosis of Pendred Syndrome, a condition that can have autosomal recessive inheritance; and would like to continue the use of specimens from donor 8552 (Dawson) acknowledging the potential increased risk of having a child affected with Pendred Syndrome. 
I understand the risks associated with using donor semen donated by Donor 8552 (Dawson) who has an offspring with a clinical diagnosis of Pendred Syndrome, a condition that can have autosomal recessive inheritance; and would like to discontinue the use of specimens from donor 8552 (Dawson) based on the potential increased risk of having a child affected with Pendred Syndrome. 
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Signed by Seattle Sperm Bank
Signed On: October 5, 2021


Signature Certificate
Document name: Informed Consent For Donor 8552 Dawson
lock iconUnique Document ID: 2723cfa54d93e74ee2e0a6b064c2c8ceeaacb572
Timestamp Audit
October 5, 2021 11:55 am PDTInformed Consent For Donor 8552 Dawson Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177