First Name
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Surname
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Mailing Address
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Phone
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Date of Birth (dd/mm/yyyy)
Email Address
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 Invitee for over 500 genes (costs US$299 for one person and US$225 for a partner)
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 testing of 556 genes for females and 513 genes for males. I understand what the carrier screening test is for. I have had the opportunity to ask questions and I am satisfied with the explanations and answers to the questions. I consent for my results to be provided by email or over the phone. I understand that genetic counselling will be available for myself and my family if required.
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Partner Details
Partner Name
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Partner Date of Birth (dd/mm/yyyy)
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