First Name
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Surname
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Sex at Birth
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Mailing Address
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Phone
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Date of Birth (dd/mm/yyyy)
Email Address
Medicare Card Number
General Practitioners Details
GP's Name
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GP's Address
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Select your test
Please select which test you would like to undergo and then consent to the test by ticking the box.
Funded testing through Wolper
Privately funded testing through Virtus Genetics for 390 genes (costs $610 after Medicare rebate)
I have a partner who is also undergoing carrier screening
I give consent for the use of my sample for testing for specific gene faults in the genes involved in cystic fibrosis, Tay-Sachs disease, Canavan disease, Fanconi anaemia, familial dysautonomia, Niemann-Pick disease, Bloom syndrome, mucolipidosis IV and glucogen storage disease 1a, Fragile X and Spinal Muscular Atrophy. I have had the opportunity to ask questions and I am satisfied with the explanations and answers to the questions. I understand that genetic counselling will be available for myself and my family if required. I consent for my results to be provided to me by email or telephone.
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I give consent for storage of my sample after testing is completed for further genetic testing related to me after my written consent has been obtained. I understand that my sample will be stored in good faith for an indefinite time, but they may not remain in a suitable state for testing. If I do not consent for storage, then my sample will be discarded after testing is completed according to laboratory accreditation requirements.
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I give consent for the use of my DNA sample for testing of 390 genes (in females) or 361 genes(in males). I've had the opportunity to ask questions and I'm satisfied with the explanations and answers to the questions. I understand that genetic counselling will be available for myself and my family if required. I consent for my results to be provided to me by email or telephone.
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Partner Details
Partner Name
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Partner Date of Birth (dd/mm/yyyy)
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