WP E-Signature by Approve Me - Sign Documents Using WordPress -

Informed Consent For Donor 14587 Latimer

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

	The undersigned patient seeks to use donated semen from Donor 14587 (Latimer) collected by the Seattle Sperm Bank for reproductive use.
	Patient understands that donor has tested positive as a carrier of Mitochondrial Complex I Deficiency (ACDA-9-Related) (ABCA9). .
	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 Mitochondrial Complex I Deficiency (ACDA-9-Related) (ABCA9). 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 Mitochondrial Complex I Deficiency (ACDA-9-Related) (ABCA9).

Please select ONE of the following boxes:

I DECLINE Testing	I understand the risks associated with using donor semen donated by Donor 14587 (Latimer) that has tested positive as a carrier of Mitochondrial Complex I Deficiency (ACDA-9-Related) (ABCA9), 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 14587 (Latimer) that has tested positive as a carrier of Mitochondrial Complex I Deficiency (ACDA-9-Related) (ABCA9), 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.

Partner or Spouse Name
(if applicable):

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Signed by Seattle Sperm Bank
Signed On: October 23, 2024

Timestamp

Audit

October 23, 2024 7:10 am PST

Informed Consent For Donor 14587 Latimer Uploaded by Seattle Sperm Bank - [email protected] IP 50.175.77.114