Informed Consent For Donor 8598 Carter


(“Patient to be inseminated”) hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 8598 (Carter) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Phenylketonuria (PKU) and Limb-Girdle Muscular Dystrophy type 2I (LGMD2I).
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 Phenylketonuria (PKU) and Limb-Girdle Muscular Dystrophy type 2I (LGMD2I). 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 Phenylketonuria (PKU) and Limb-Girdle Muscular Dystrophy type 2I (LGMD2I).
Please select ONE of the following boxes:

I understand the risks associated with using donor semen donated by Donor 8598 (Carter) that has tested positive as a carrier of Phenylketonuria (PKU) and Limb-Girdle Muscular Dystrophy type 2I (LGMD2I), 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 8598 (Carter) that has tested positive as a carrier of Phenylketonuria (PKU) and Limb-Girdle Muscular Dystrophy type 2I (LGMD2I), 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: July 20, 2018

Signature Certificate
Document name: Informed Consent For Donor 8598 Carter
Unique Document ID: 600114b2f695a641186c168010a118efc3f43937
Timestamp Audit
July 20, 2018 7:53 am PSTInformed Consent For Donor 8598 Carter Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 192.168.200.112