Informed Consent for Genetic Testing

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.

Signature:_____________________________________              Date:  ____________________

Witness:  _____________________________________              Date:  ____________________

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© 2001 The Genetics Center, Inc, All Rights Reserved.                                     This page last updated on October 3, 2001