Informed Consent For Donor 14030 Bennett


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 14030 (Bennett) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that donor has tested positive as a carrier of Peroxisome Biogenesis Disoreder Type 1.
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 Peroxisome Biogenesis Disoreder Type 1. 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 Peroxisome Biogenesis Disoreder Type 1.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 14030 (Bennett) that has tested positive as a carrier of Peroxisome Biogenesis Disoreder Type 1, 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 14030 (Bennett) that has tested positive as a carrier of Peroxisome Biogenesis Disoreder Type 1, 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: June 22, 2021


Signature Certificate
Document name: Informed Consent For Donor 14030 Bennett
lock iconUnique Document ID: b62f8d4c813870efca9743e62db475829f810990
Timestamp Audit
June 22, 2021 12:23 pm PSTInformed Consent For Donor 14030 Bennett Uploaded by Seattle Sperm Bank - canam@seattlespermbank.com IP 75.151.115.177