By signing below, I hereby authorize Dr. _________________________________
to obtain genetic testing for ________________________________ .
The indication (reason) for the testing is: ________________________________
.
My doctor and/or associates have provided counseling regarding
the testing and have
explained the following to me:
1. A general description
of the disease and purpose for the test and that no testing other than as
described above will be performed on this sample
2. The fact that genetic
counseling may be highly recommended to discuss positive
results or negative results
3. The fact that genetic
testing may not give a definite answer about diagnosis, i.e., both
false negative results and false positive results may occur
4. That test interpretation
may depend on accurate family history information
5. That in some cases,
genetic testing may discover non-paternity (someone who is not
the real father), or other previously unknown information about family relationships
6. That appropriate
safeguards will be taken to maintain the confidentiality
of my records, that it is my responsibility alone to inform other family members
of genetic risks they may have, and that results will only be released to
my physician(s)
Under Section 79-l of the New York State Civil Rights
Law, certain additional requirements for
informed consent and testing apply. Provisions
of this law strengthen protection for patients and
include restrictions on disclosure (other than to the ordering physician)
of genetic testing results and requirements for laboratories
wishing to retain samples.