UCD DNA Diagnostic
Laboratory Get a PDF
version Phone: (303)
724-3801
Mail
Stop 8313, 12800 E. 19th
Avenue Fax: (303)
724-3802 PO
Box 6511 Aurora, CO 80045 DNA Analysis Patient Information and Consent Patient
Last Name:
First
Name: MI: Hospital/ID Number: ______________________
DOB___/___/______
Sex: M__ F__ Patient Address and
Telephone Please check here YES__ NO__ Refusal to
permit use of my sample for research will not affect this test procedure. I am
free to withdraw this consent at any time without prejudice to future care. I
can withdraw my consent by calling the laboratory director. 12. Any disputes that arise in relation to the DNA
testing shall be governed by the laws, rules and regulations of the State of
Colorado, as are now in effect or as may be later amended or modified,
without reference to the choice of law or rules of any state. I submit to the
exclusive jurisdiction and venue of any court having subject matter
jurisdiction located in the City and County of Denver, State of Colorado, including the United States District Court for the District of Colorado, in the
event of any litigation concerning the DNA testing, regardless of
where this consent is executed or where I reside. Name
of Physician or Geneticist: ____________________________________________________ Signature of Patient or Legal
Printed Name of Legal
Signature of
Witness: Guardian:
Guardian: __________________________
__________________________
__________________________ __________
(date)
_________
(date)
_____________________________ I
request DNA analysis for: (genetic
condition)
_____________________________
The intended purpose
is:
_____________________________
__ Prenatal __ Screening __ Diagnostic __ Carrier Status
Telephone: ____________________
__ Predictive __ Other ________________________________
I give my consent to have my sample sent to the UCD DNA Diagnostic Laboratory
for DNA testing for the above-designated genetic condition. I have discussed
the principles, the benefits and the risks of this testing with a
physician/genetic counselor, and I have had my questions answered. I
understand the following benefits, risks and limitations:
1. While DNA testing is a valuable diagnostic tool, it may not always give a
definite answer about the genetic status of an individual. More specific
information will be reported with the results of the test.
2. This DNA test is specific only for the condition named above.
3. While mutation and/or linkage analysis often gives precise information,
there are several possible sources of error. These include but are not limited
to: clinical misdiagnosis of the condition, sample misidentification, incorrect
paternity identification, and sample contamination.
4. The test is complex. It is not FDA approved. It uses some reagents
produced for research purposes only. There is always a possibility that a
diagnostic error may occur. In addition, the laboratory may have difficulties
analyzing my sample and a second sample may be requested.
5. The test may reveal previously unrecognized biological relationships, such
as non-paternity. DNA tests may also reveal a genetic condition in another family
member.
6. After the DNA testing of my sample is completed, the DNA may be used
anonymously for medical research.
7. I understand there will be a fee for this
DNA testing ______________________________ (signature)
8. DNA testing may involve emotional stress and may result in
discrimination (insurance- or work-related). The results of this testing will
be treated in the standard manner to ensure medical confidentiality. The
laboratory is obligated to release test results to my insurance provider if the
provider asks for them in order to pay for the test.
9. Follow-up genetic counseling is available. I can contact the laboratory
director, Elaine Spector, Ph.D. at (303) 724-3801 for information about the
test or genetic counseling.
10. I can decide not to receive the results of the test, but I will still be
responsible for the cost of the test.
11. In the event of physical injury resulting from this procedure the
University of Colorado School of Medicine is not able to offer financial
compensation or to absorb the cost of medical treatment. However, necessary
facilities, emergency treatment and professional services will be available
just as they are to the community generally.