Informed Consent For Donor 9869 Mason


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 9869 (Mason) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive of having 15q13.3 microdeletion syndrome.
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 of having 15q13.3 microdeletion syndrome. 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 15q13.3 microdeletion syndrome.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 9869 (Mason) that has tested positive of having 15q13.3 microdeletion syndrome, and I wish to continue the use of specimens from Donor 9869 (Mason).
I understand the risks associated with using donor semen donated by Donor 9869 (Mason) that has tested positive of  having 15q13.3 microdeletion syndrome, and I do not wish to continue the use of specimens from Donor 9869 (Mason).
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Signed by Seattle Sperm Bank
Signed On: August 18, 2020

Signature Certificate
Document name: Informed Consent For Donor 9869 Mason
lock iconUnique Document ID: 425d10175b33b77bddbc7f828dd1a4ef0e1ccb00
Timestamp Audit
August 14, 2020 1:32 pm PSTInformed Consent For Donor 9869 Mason Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 75.151.115.177