REPROMED DONOR # 3292

Expanded Carrier Screening (ECS) is a form of genetic testing that may determine if the individual is a carrier
for a certain genetic disease that can be inherited. You can learn more about ECS by clicking here:

www.repromed.ca/ecs

Donor 3292 has participated in ECS with Counsyl.

Information about Donor 3292’s ECS is available by clicking the icon in the Donor Portfolio column
on the Catalogue Page.

Donor 3292 is a carrier for Hexosaminidase A Deficiency (Including Tay-Sachs Disease)

Donor 3292 requires additional consent in order for the vials to be released and shipped to your clinic.

To assist recipients with more information about ECS, donors that have completed testing have their results
provided to recipients in advance of vial purchase. This report can be shared with your treating physician
to assess risk factors associated with using this donor. It is important to note that in some cases, an
Acknowledgment Consent must be completed before the vials are released and shipped to your clinic.
 RECIPIENT ACKNOWLEDGMENT OF DONOR GENETIC CARRIER STATUS
REPROMED DONOR # 3292

I hereby acknowledge that I have received the genetic test results for this donor and he is a positive carrier
for the following:

Hexosaminidase A Deficiency (Including Tay-Sachs Disease)

Detailed information regarding the risks associated with carrier status, and the genetic condition(s), listed
above has been available to me by ReproMed Ltd.

I understand the risks associated with using semen donated by ReproMed Donor #3292, and I have been
provided with the information regarding the associated disease risks. I have had the opportunity to ask
questions, obtain answers to my questions, and discuss this information with my treating physician and/or
genetic counselor.

ReproMed Ltd strongly recommends that I (or my egg donor) undergo carrier testing for the genetic
condition(s) listed above, which can be ordered by my physician.

I understand that these risks are significantly reduced if the biological parents’ are not carriers for the same
condition(s). I further understand that if both biological parents are carriers for the same condition(s), then
any resulting child is at an increased risk for having that condition.

I understand and accept the risks of conceiving a child with this donor’s semen and release ReproMed Ltd,
its physicians, technicians, staff and related and affiliated corporations from all claims howsoever caused
and confirm that I wish to proceed with donor insemination. Furthermore, I have read, understood and
accepted ReproMed’s Donor specimen Purchase of Use Agreement.

Signature of patient to be inseminated Date

Printed name of patient to be inseminated Date

Signature of partner (if applicable) Date

REPROMED LTD.
56 Aberfoyle Crescent Suite 300 Etobicoke, ON M8X 2W4 416-233-8111 FAX: 416-233-9180

Data Assisted Donor Selection

Donor Portfolio

I Donor ID : 3292 ReproMed Ltd.

Specimen Preparation Available: Standard and Pre-Washed
Geographic Restriction:

Physical Features

General:
Race: Caucasian Blood Type: B Rh Factor: Rh-

Maternal Ethnic Ancestry: Russian/German Paternal Ethnic Ancestry: Russian/Ukrainian

Height: 73Inches Weight: 211 Pounds {lbs) Bone Size: Medium

Eye Color: Brown Predominant Hand: Right Complexion: Medium

Allergies?: Yes Specify: Powder milk in childhood

Teeth Condition:Good Exercise: Regularly

Hair:
Color: Light Brown Texture: Straight Condition of Hair: Donor's: Thick
Male Sibling's: Receding
Father's: Average
Comments:

Distinguishing Characteristics

Freckles: None Location:

Dimples:Yes Cleft Chin: No

Other:

Vision
Vision without Correction : Excellent Vision with Correction : Fair

Nearsighted: No Farsighted: No Other:

Page 1