病理学和实验室医学部精密诊断 - 遗传疾病注意:如果不存在,不完整或未签名的同意书,我们的政策是提取DNA并在进行测试之前等待文书工作。Patient's Last Name: __________________________________ First Name: __________________________________ MI: ____ Hospital/ID Number: ________________________ DOB ______/______/_______ (MM / DD / YYYY) Sex: M____ F____ O ____ Guardian's Name(s) and relationship to patient (if patient is a minor): ___________________________________________________ Patient's full mailing address + zip________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Phone, H: __________________________ W: _________________________ ext.______ Mobile: ____________________________ Email address: ______________________________________________________________________________________________ I request DNA analysis for (genetic condition): __________________________________________________________________ Test Number(s) _________________________________________________ The intended purpose is: __ Diagnostic __ Carrier identification __ Prenatal diagnosis __其他__测序__ __特定已知突变(S)突变图__缺失/重复我同意将样本发送到CHCO Precision Precision诊断实验室,以进行DNA测试,以进行高于指定的遗传条件的DNA测试。我已经与医生 /遗传学家 /遗传顾问讨论了该测试的原理,利益和风险,并且我已经回答了问题。我了解以下好处,风险和局限性:
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