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Informed Consent For Donor 12587 Pepin

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

	The undersigned patient seeks to use donated semen from Donor 12587 (Pepin) collected by the Seattle Sperm Bank for reproductive use.
	Patient understands that donor has tested positive as a carrier of Phenylalanine Hydroxylase Deficiency and Factor XI Deficiency.
	Patient is aware of the aforementioned exceptions and genetic disease risks associated with each. Client understands that the donor is a carrier of factor XI deficiency, otherwise known as hemophilia C. Carriers of hemophilia C sometimes manifest symptoms, such as moderate bleeding following surgery or trauma. There is a 50% chance that any embryo/child resulting from this donor will inherit the donor’s F11 mutation and therefore may have an increased bleeding risk. If the egg source is also a carrier of sickle cell anemia, there would be a 25% chance to have a child affected with factor XI deficiency/hemophilia C. Patient is encouraged to discuss this with their clinician and has the opportunity to discuss these risks with a genetic counselor at Seattle Sperm Bank at no charge.
	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 Phenylalanine Hydroxylase 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 Phenylalanine Hydroxylase Deficiency.

Please select ONE of the following boxes:

I DECLINE Testing	I understand the risks associated with using donor semen donated by Donor 12587 (Pepin) that has tested positive as a carrier of Phenylalanine Hydroxylase 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 ACCEPT Testing	I understand the risks associated with using donor semen donated by Donor 12587(Pepin) that has tested positive as a carrier of Phenylalanine Hydroxylase 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: August 26, 2022

Timestamp

Audit

April 30, 2021 2:17 pm PDT

Informed Consent For Donor 12587 Pepin Uploaded by Seattle Sperm Bank - [email protected] IP 75.151.115.177