Healthcare DNA Testing Form

Healthcare DNA Testing Form

Patient Information

Gender: Male Female Other / Prefer not to say

Emergency Contact

Insurance Information

Medical History

Test Details / Specimen

Specimen Type: Buccal swab Blood Saliva Other

Collection Date:    Collection Time:

Chain of custody maintained: Yes No

Purpose of Test

Intended purpose (check all that apply): Relationship / Paternity testing Medical diagnosis / carrier screening Forensic / legal Research Other

Consent and Authorization

I authorize the laboratory to perform DNA testing on my specimen for the purpose(s) specified above. I understand that the procedure involves collection of a buccal swab, blood draw, or saliva sample and that risks are minimal but may include minor bleeding, infection, or discomfort. I acknowledge that the laboratory will use validated methods consistent with industry standards.

I understand the potential benefits include diagnostic information, confirmation of biological relationships, or data relevant to medical care. I understand there may be no direct benefit and results are not guaranteed to provide definitive medical or legal conclusions in all cases.

I authorize the laboratory and associated health care providers to release test results, reports, and relevant medical information to the persons or entities designated below and to exchange information necessary for billing and care coordination.

I understand that genetic test results are protected health information. I authorize use and disclosure of my genetic information for treatment, payment, and health care operations as required for testing and reporting. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected under federal medical privacy regulations.

I authorize storage of leftover specimens for a period necessary for quality control, confirmation testing, or as required by law. I understand leftover specimens may be destroyed or anonymized; if specimens are to be used for research or commercial purposes separate authorization will be requested unless I indicate consent below.

Research use of specimens (optional): I consent to de-identified research use of my specimen

I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures made prior to receipt of revocation.

I understand that certain legal proceedings or court orders may require disclosure of test results despite this authorization. I agree to pay any fees associated with testing as set by the provider unless otherwise agreed.

No expiration (until revoked in writing)

Legal Notices and Certifications

Certification: By signing below I certify that I am the patient named on this form or the legal guardian authorized to consent on behalf of the patient. I certify that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that intentional misrepresentation of identity, specimen origin, or intended use may subject me to legal penalties.

Confidentiality: The laboratory will maintain confidentiality of records in accordance with applicable law. Limited disclosures for the purposes of testing, quality assurance, accreditation, and billing may be made consistent with this authorization.

Liability: To the fullest extent permitted by law, the laboratory, specimen collector, and referring clinician are not liable for indirect or consequential damages arising from testing, except for damages caused by gross negligence or willful misconduct.

Additional Information

Consent Confirmation: I have read and understand the information provided and consent to DNA testing as described above.

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