REPROMED DONOR # 3291

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 3291 has participated in ECS with Counsyl.

Information about Donor 3291’s ECS is available by clicking the icon in the Donor Portfolio column on
the Catalogue Page.

Donor 3291 is a carrier for Ataxia-telangiectasia ; GJB2-related DFNB1 Nonsyndromic Hearing Loss and
Deafness

Donor 3291 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 # 3291

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

Ataxia-telangiectasia

GJB2-related DFNB1 Nonsyndromic Hearing Loss and Deafness

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 #3291, 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 . 416-233-81I I FAX: 416-233-9180

Data Assisted Dono, Selection

Donor Portfolio
June 29,2020

Donor lD : 3291 ReproMed Ltd.

Specimen Preparation Available: Standard and Pre-Washed

Geographic Restriction :

Physical Features

General:
Race: Mixed Blood Type:A Rh Factor:Rh+

Maternal Ethnic Ancestry: polish Paternal Ethnic Ancestry: lraqi

Height: 71 lnches Weight: 180 Pounds (lbs) Bone Size: Medium-Large

Eye Color: Brown Predominant Hand:Left Complexion: Medium

Allergies?: No Specify:

Teeth Condition:Good Exercise: Regularly

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

Disti nq u ish i nq Characteristics

None
Freckles: Location:

Dimples:No Cleft Chin:No

Other:

Vision
Vision without Correction : Fair Vision with Correction : Excellent

Nearsighted: Yes Farsighted: No Other:

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Donor lD : 3291 ReproMed Ltd.

Hearinq

Hearing NormaliAbnormal : Normal

lf Abnormal, Specify:

Family H

Domestic Status : Single Reliqious Preference:

Childhood : Roman Catholic
Blood Siblinqs: Male: 0 Female:0
Currently : Agnostic
Multiple Familial Births : Relation of Births :

Children Fathered : 0

Male Children: O # Known Additional Live Births :

Female Children :0 Total# of Live Births :

Proven Fertility by IVF :

Educational H

Donor: 3 HighSchool Lifeguard, Swim lnstructor

Mother: 3 College Diploma in Business Property Manager

0 School
:

Father: : High Hot Room Supervisor

Highest Degree Earned :HighSchoo Specify : BA Student of Justice Studies

Future Occupation Goals : Become a police officer

Subiects Enioved Least

Math.
Natural Science...............
Social Science......

Communication
Languages......................X
Computers..
History, Geography Other..........

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Donor lD : 3291 ReproMed Ltd.

Skitls and Abilities

Math........... High
...... Specify Did well in math classes

Mechanical. ......High Specify Was designing robots in robotics team

Athletic....... .......High Specify Played many sports and did military training well

Musical (lnstrumental)........ Average Specify

Musical(Vocal)...................Average Specify

Language (Written).............Above-Average Specify Does well on essays & reports for work
Language (Verbal).............. Average Specify

Artistic (Theater).... Above-Average Specify Took part in schoot plays & can impersonate well

Artistic (Drawing/Painting)...Average Specify Gan draw diagrams & plans well, but it is messy a bit.

Other Skills :Quick learner, adaptable, resilient & very creative

Use of Leisure Time : Traveling, Sports, Biking, Visiting social events, Trying new things

Preferences

Pets............................Like Specify

Music..........................Like Specify Like all music forms, the genre depends on mood.

Team Sports..............Like Specify I really enjoy any team sports. Football, paintball.

lndividual Sports.........Like Specify Shot put, swimming.

Schoo1........................NoOpinion Specify

Goals/Am bitions/Plans/Feel inqs

lnitiate Own
Help Peop|e.................. X Decent Wage Leve|......... Business/ Own Boss.. Public Service........ X

Good Job...................... X Trave|............................... X God/Re|igion.............. Politics....'............... X

Become Financial
Marriage/Family/Kids.... X lndependance................. X lmmediate Family...... X Success......

lmprove Environment....X Financial Security............ X SocialAcceptance..... To be Happy.......... X

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Donor lD : 3291 ReproMed Ltd.

Personality Traits

Extrovert........ X Moody............ Friend|y............ X Concerned Well-adjusted... X

lntrovert.......... Quiet............... Perfectionist..... Kind..................... X Pessimistic.......
Passive.......... Loud............... X Enthusiastic..... X Happy.................. X 1ntense............. X
Submissive.... Thoughtful....... X Energetic......... X Temperamental.... Carin9.............. X
Easy-Going.... X Humorous....... X Adventurous..... X lntelligent............. X Egotistic............
Out-Going...... X Creative.......... X

Anatomical Features

ace Shape : Nose Shape : Ear Lobes :

fr

t\1\
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J
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ti\1 1/
,/ ."
t,\*:
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Eye Set : Eye Shape : Lips Shape : Body Shape :

i
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?fiffi3 t r trllng
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Donor lD : 3291 ReproMed Ltd.

Donor Motivation

This Donor Would: Donor's Motivation:

Participate Without Reimbursement...Yes Fam ily Infertility Experience.

Participate Without Anonymity........... Yes Genetic Donation for Procreation.........

* Meet With Recipient Coup|e.............. Yes
* Finacial Reward
Meet With Donor Offsprin9................ Yes
Assist Anonymous lnfertile Couples.... X

Other Motivation :Donor 3291is an Open-lD (ldentity

Disclosure) donor

* Note: Present legal statutes & standards prohibit donor/recipient disclosure

Medical History

Allergies..... Epilepsy...... Muscular Dystrophy... Stroke.........

Color B1indness................ Migraine...... Myasthenia Gravis..... Heart Attacks........................".
Deafness.... Glaucoma... Parkinson's. Congenital Heart Problem.......
Blindness.... Goiter......... Psoriasis..... Cleft Palate or 1ip...................
Undescended Testicles.... Gout........... Ulcers Retinob|astoma.......................
Diabetes..... Hermaphroditism.... Varicose Veins........... Alcoholism..
Juvenile Arthritis............... Hernia (lnguinal).... Cirrhosis..... Emotional Disturbance
Hemophilia. Hypertension......... Cryptorchidism........... Mental Retardation.
Cataracts.... Club Foot.... Mental I11ness............. Blood Disorder (Anemia,etc.)..
Cancer (Leukemia, etc).... Dyslexia...... Kidney Disease Convulsive Disorders....
Cystic Fibrosis....... Emphysema Lymphedema............. Dislocated Hip (Congenital)....
Ec2ema............................. X Jaundice..... Drug Use.... Other Physical Anomalies......
Anti-CMV Reactive (lgc)... X Tay Sachs.. Sickle Cell Anemia..... Tha|essemia..........................

Comments : Donor has eczema

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