Informed Consent for Donor 10896 Bach


("Patient to be inseminated") hereby acknowledge and represent as follows:
The undersigned patient seeks to use donated semen from Donor 10896 (Bach) collected by the Seattle Sperm Bank for reproductive use.
Patient understands that Donor 10896 (Bach) has tested positive as a carrier of Glutaric Acidemia Type 1 and Leber Congenital Amaurosis 10 And Other CEP290-Related Ciliopathies.
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 Glutaric Acidemia Type 1 and Leber Congenital Amaurosis 10 And Other CEP290-Related Ciliopathies. 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 Glutaric Acidemia Type 1 and Leber Congenital Amaurosis 10 And Other CEP290-Related Ciliopathies.
Please select ONE of the following boxes:
I understand the risks associated with using donor semen donated by Donor 10896 (Bach) that has tested positive as a carrier of Glutaric Acidemia Type 1 and Leber Congenital Amaurosis 10 And Other CEP290-Related Ciliopathies, 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 10896 (Bach) that has tested positive as a carrier of Glutaric Acidemia Type 1 and Leber Congenital Amaurosis 10 And Other CEP290-Related Ciliopathies, 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 genetic testing.
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Signed by Seattle Sperm Bank
Signed On: August 20, 2025


Signature Certificate
Document name: Informed Consent for Donor 10896 Bach
lock iconUnique Document ID: 40bbc13649f6a8fb347dc132786c8c327d7da5fa
Timestamp Audit
August 6, 2025 1:11 pm PDTInformed Consent for Donor 10896 Bach Uploaded by Seattle Sperm Bank - [email protected] IP 50.175.77.114