Consent

Genetic Testing Consent Form

2 pages14 fieldsHIPAA-ready

Form preview

formisoft.com/f/genetic-testing-consent
Patient Name
Date of Birth
Test Type & Indication
Select...
Scope of Testing Explained
Potential Results & Limitations
Secondary Findings Preference
Family Implications Acknowledged
Genetic Privacy & GINA Rights
Specimen Storage & Biobanking Consent
Research Data Sharing Consent
Genetic Counseling Acknowledgment
Right to Withdraw Consent
I agree to the terms above
Sign here
Patient Signature
Sign here
Ordering Provider Signature
Sign here
Submit

The Genetic Testing Consent Form provides comprehensive informed consent documentation for patients undergoing clinical genetic or genomic testing. This template addresses the unique ethical and legal considerations inherent in genetic testing, including the scope of testing (single-gene, multi-gene panel, whole-exome, or whole-genome sequencing), the types of results that may be returned (positive, negative, variant of uncertain significance), and the possibility of incidental or secondary findings unrelated to the primary indication. The form explains concepts such as analytical validity, clinical validity, and clinical utility in patient-accessible language.

The consent covers critical aspects specific to genetic medicine including the implications of test results for biological relatives, the potential for genetic discrimination (with reference to GINA protections and state-specific genetic privacy laws), the limitations of negative results in the context of residual risk, and the distinction between diagnostic and predictive testing. Patients are given the option to elect or decline categories of secondary findings consistent with ACMG recommendations for reporting of secondary findings in clinical exome and genome sequencing.

Data privacy sections detail how genetic specimens and sequence data will be stored, whether de-identified data may be contributed to research databases or variant repositories (e.g., ClinVar, gnomAD), and the patient's rights regarding biobanking and future reanalysis. Pre-test and post-test genetic counseling acknowledgments are captured, along with dual signatures from the patient and ordering provider, creating a complete audit trail that satisfies CAP/CLIA laboratory requirements and institutional policies for genomic medicine.

What's included

  • Test scope and indication documentation
  • Secondary findings election or declination
  • Genetic privacy and anti-discrimination rights
  • Specimen storage and biobanking preferences
  • Pre-test and post-test counseling acknowledgment
  • Dual signatures with ordering provider attestation
  • Consent agreement with e-signature

Who uses this template

  • Clinical genetics and genomic medicine programs
  • Hereditary cancer risk assessment clinics
  • Prenatal and reproductive genetics screening
  • Pharmacogenomic testing before medication therapy

All form fields

14 fields across 2 pages. Customize any field after signing up.

Patient NameText
Date of BirthDate
Test Type & IndicationDropdown
Scope of Testing ExplainedCheckbox
Potential Results & LimitationsCheckbox
Secondary Findings PreferenceMultiple Choice
Family Implications AcknowledgedCheckbox
Genetic Privacy & GINA RightsCheckbox
Specimen Storage & Biobanking ConsentMultiple Choice
Research Data Sharing ConsentMultiple Choice
Genetic Counseling AcknowledgmentCheckbox
Right to Withdraw ConsentConsent Agreement
Patient SignatureE-Signature
Ordering Provider SignatureE-Signature

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