CONSENT FOR BANKING OF DNA SAMPLE

Patient's Name: _______________________________________________________________

Patient's ID#:____________________________

Referring Center:_______________________________________________________________

I am requesting that my DNA sample be banked at Comprehensive Genetic Services, SC (CompGene) or at its designated responsible party for possible future molecular genetic studies. There is a one time fee for this service. I understand that my consent for the use of this banked DNA sample can be transferred from me to another designated party by completion of a "Transfer of Ownership of Banked DNA Sample" form available from CompGene or from its designated responsible party. I understand in the event of my death, my DNA sample will become part of my estate if this form has not been completed.

I understand that future testing may not yield results for any combination of the following reasons: 1) unavailable blood or tissue samples from critical family members; 2) uninformativeness of the available genetic markers; 3) maternal contamination of prenatal samples; 4) technical reasons.

I understand that future DNA analysis may yield information on biological paternity, the results of which will not be disclosed to me or other family members unless biological paternity is relevant in counseling for the reason for which I have submitted this DNA sample.

I agree to give blood (about 2 teaspoons) or a tissue sample for DNA extraction for DNA banking. I understand that the procedure used to collect the blood or tissue sample has inherent minimal risks which have been explained to me. An additional blood or tissue sample may have to be obtained if the quality or quantity of the DNA sample is considered by laboratory personnel to be inadequate. My (my child's) DNA sample will be stored in the DNA bank at CompGene or at its designated responsible party.

I DO/DO NOT agree to the use of my (my child's) DNA in research and development/ quality control at CompGene or at other laboratories under the condition of maintaining confidentiality. I understand that any information identifying me (my child) will be kept confidential and that any exchange of samples or information will be coded.

No compensation will be given to me (my child) nor will funds be forthcoming to me (my child) due to invention resulting from research and development using my (my child's) DNA.

Your signature on this form indicates that you have understood to your satisfaction the information regarding DNA banking. In no way does this waive your legal rights nor release the investigators, sponsors, or involved institutions from their legal and professional responsibilities. If you have further questions concerning matters related to this consent, please discuss them with your medical geneticist, genetic counselor, or referring physician.


(Signature of patient or legal guardian) _____________________ (Date) _____________


(Signature of witness) ___________________________________ (Date) _____________