Informed Consent 12145 Kendrick


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12145 (Kendrick) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Short Chain Acyl-CoA Dehydrogenase Deficiency.
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 GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Short Chain Acyl-CoA Dehydrogenase Deficiency. 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 GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Short Chain Acyl-CoA Dehydrogenase Deficiency.
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I understand the risks associated with using donor semen donated by Donor 12145 (Kendrick) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Short Chain Acyl-CoA Dehydrogenase Deficiency, 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 12145 (Kendrick) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness and Short Chain Acyl-CoA Dehydrogenase Deficiency, 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: October 23, 2018


Signature Certificate
Document name: Informed Consent 12145 Kendrick
lock iconUnique Document ID: 9d9e4f80126f2bcaa9fcb2617dcadb26482b499c
Timestamp Audit
October 23, 2018 3:32 pm PDTInformed Consent 12145 Kendrick Uploaded by Seattle Sperm Bank - [email protected] IP 75.151.115.177