Healthcare Patient Genetics Consent Form

Healthcare Patient Genetics Consent Form

Patient Information

Insurance Information

Medical History

Genetic Test Description and Specimen

I authorize genetic testing for the following test(s) or panel(s):

Specimen(s) to be collected: Blood Saliva Buccal swab Other:

Risks, Benefits and Limitations

I understand that genetic testing may identify variants that explain, or may not explain, a health condition. Results may be positive, negative, or of uncertain significance. There may be implications for family members. Testing may produce unexpected findings unrelated to the reason for testing.

Limitations include incomplete knowledge of genetic variants, limitations of current laboratory methods, and the possibility that a disease-causing variant is not detected. Benefits may include clarification of diagnosis, informing treatment or surveillance, and informing reproductive decision-making.

Confidentiality and Disclosure

Genetic test results are part of the medical record and are subject to protections under applicable privacy laws. Information may be disclosed to treating providers and to persons or entities authorized below. There are legal protections against certain types of genetic discrimination, but such protections vary by jurisdiction and circumstance.

Include results in medical record: Yes

Storage, Future Use and Research

I authorize the laboratory to store my specimen and/or derived data for the period indicated below for quality control or future testing. I understand I may separately consent or decline the use of my de-identified sample/data for research purposes.

Store specimen for:    I consent to de-identified research use

Right to Withdraw and Expiration

I understand I may withdraw this authorization at any time by providing written notice to the ordering provider or laboratory. Withdrawal will not affect disclosures already made based on this authorization.

This authorization will expire on:   If left blank, authorization will remain in effect for the duration permitted by the institution's policies and applicable law.

Certification and Acknowledgment

By signing below I certify that I have read and understand the information in this form, that the nature and purpose of the genetic testing have been explained to me, that I have had the opportunity to ask questions and have received satisfactory answers, and that I authorize the genetic testing and disclosures described above. I understand the potential medical and non-medical implications of genetic information.

If signing as a personal representative, parent or legal guardian, I certify that I am authorized to make healthcare decisions for the patient identified above and that the relationship and authority are stated below.

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