Consent for Molecular Diagnostic Testing
Comprehensive Genetic Services SC
Molecular Genetics Laboratory
Patient's Name: ________________________________________________________
Patient's ID#: _____________________
The blood or tissue sample I (my child) have (has) provided is required to isolate DNA with which to
undertake molecular genetic testing for:
- The molecular genetic testing may provide a diagnosis of or indication of risk for myself or my offspring for the condition specified above.
- I understand that this test 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 pre-natal samples; 4) technical reasons.
- I understand that DNA analysis may yield information on biological paternity, the results of which will not be disclosed to me unless biological paternity is relevant in counseling for the reason for which I have
submitted this DNA sample. I agree to provide a family history to the best of my knowledge.
- I DO/DO NOT agree to give blood (about 2 teaspoons) or a tissue sample for DNA extraction for the purpose of diagnosis/research and development/quality control. I understand that the procedure used to collect the blood or tissue samples has inherent minimal risks which have been explained to me.
- An additional blood or tissue sample may have to be obtained in the absence of results, or if the results are inconclusive.
- My (my child's) DNA will be stored in the DNA bank at Comprehensive Genetic Services, SC, Milwaukee, WI or its responsible delegate
- I DO/DO NOT agree to the use of my (my child's) DNA in research and development/ quality control at Comprehensive Genetic Services, SC 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 molecular genetic testing and agree to participate. 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 and date)
(Signature of witness and date)