I,_______________________, request that an attempt be made to assess the probability that I or my _________________ might have inherited the genetic condition _____________________. I understand that the DNA for analysis is to be obtained from a) blood cells, b) skin sample or c) ____________________. The methods, discomfort and risks of obtaining the specimen have been explained to me. I also understand that:
1. The test procedure is specific to the genetic condition mentioned above and cannot determine the complete genetic makeup of an individual.
2. Lack of cooperation by key relatives in providing blood samples may decrease the accuracy of the test result and/or the ability to perform the test.
3. An error in diagnosis may occur if there is anything incorrect in what I say about the biological relationships of relatives involved.
4. Sometimes the genetic pattern in a family renders the test results "uninformative", that is, not clarifying the point.
5. Even under the best conditions, current technology of this type is imperfect, and may lead to incorrect results.
6. The test results, when reported to me, may be distressing.
7. I may withdraw my consent at any time without penalty.
8. When the test has been completed and if there is any remaining unused DNA material:
O I wish for it to be stored (banked) for future testing, or
O I do not wish to bank the leftover DNA and prefer that it be destroyed.
I understand that many of the health care providers, including physicians, physician's assistants, therapists, nurse practitioners, and others who care for patients at All Children's Hospital are not the agents, servants, or employees of the Hospital, but are independent of it. I also understand that many people who care for patients at All Children's Hospital wear lab coats, name badges, or other items or apparel bearing the name or logo "All Children's Hospital," but these are purely for the security or identification purposes, and do not indicate that people wearing them are Hospital agents, servants, or employees. I specifically understand that lab coats, shirts, identification badges, and similar items or apparel do not indicate any particular relationship between the person wearing them and All Children's Hospital.
I also understand that All Children's Hospital may delegate health care duties or responsibilities to independent physicians, physician's assistants, therapists, nurse practitioners, or other health care professionals. I agree that when the Hospital delegates these health care duties and responsibilities to independent persons, it is not responsible for the conduct of such persons.
I hereby release All Children's Hospital Molecular Genetics Clinical Laboratory from any injury, either physical or mental which might be sustained by either me or other members of my family as a result of the factors and hazards of techniques and evaluations involved in these diagnoses. I hereby assume all risks inherent in these procedures. All of the above has been discussed with me and I have had the opportunity to have questions answered by_______________________.