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Informed Consent 12181 Anton

("Patient to be inseminated") hereby acknowledge and represent as follows:

	The undersigned patient seeks to use donated semen from Donor 12181 (Anton) 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.
	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. 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 Aspartylycosaminuria.

Please select ONE of the following boxes:

I DECLINE Testing	I understand the risks associated with using donor semen donated by Donor 12181 (Anton) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness, 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 ACCEPT Testing	I understand the risks associated with using donor semen donated by Donor 12181 (Anton) that has tested positive as a carrier of GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness, 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

Timestamp

Audit

October 23, 2018 3:36 pm PDT

Informed Consent 12181 Anton Uploaded by Seattle Sperm Bank - [email protected] IP 75.151.115.177