Donor ID:

Donor Name:

Recipient Name:

1. This informed consent is in reference to the Donor you have chosen Semen Use.
2. “Recipient” is defined as the person using donor specimens from Cryobank America, LLC to achieve pregnancy.
3. “ Recipient” shall hereby acknowledge and represents as follows:
   • The undersigned and above listed recipient seeks to use Cryobank America, LLC collected Donor Semen from a donor that is a carrier for a genetic condition.
   • The Recipient fully understands and has reviewed the results and understands that the Donor listed above has tested positive as a carrier for a genetic condition.
   • Description of disease(s) the donor was tested positive for was provided to the recipient by all means possible.
   • The Recipient is aware of the prior exceptions and genetic disease risks that may be associated.
   • The Recipient has agreed to personally assume all risks that are associated with the Recipient’s use of semen samples collected by Cryobank America. The Recipient has reviewed the genetic testing results provided by Cryobank America and has advised a medical professional regarding these results.
   • The Recipient acknowledges that they have viewed and been provided all genetic testing results available to Cryobank America, LLC.
   • The Recipient hereby agrees to release Cryobank America, LLC and its current and former officers, directors, employees, attorneys, agents, insurers, and representatives of any liability or responsibility whatsoever for any and all outcomes, whether known currently, unknown or unsuspected, arising out of Recipients use of Cryobank America collected semen by the Donor listed above.

Recipient Printed Name:

Date: