Informed Consent For Donor 12536 Linden


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 12536 (Linden) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Cerebrotendinous Xanthomatosis.
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 Cerebrotendinous Xanthomatosis. 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 Cerebrotendinous Xanthomatosis.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 12536 (Linden) that has tested positive as a carrier of Cerebrotendinous Xanthomatosis, 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 12536 (Linden) that has tested positive as a carrier of Cerebrotendinous Xanthomatosis, 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.
Partner or Spouse Name
(if applicable):

Leave this empty:

Signature arrow sign here

Signed by Seattle Sperm Bank
Signed On: July 28, 2021


Signature Certificate
Document name: Informed Consent For Donor 12536 Linden
lock iconUnique Document ID: 271ac3c7fe25e691c740aba700712b5ad0fcdfdd
Timestamp Audit
July 28, 2021 10:20 am PDTInformed Consent For Donor 12536 Linden Uploaded by Seattle Sperm Bank - [email protected] IP 75.151.115.177