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:



__________________________________________________________________________
(specify)



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)