Declaration of Consent | Germline Diagnostics
Patient Sender / Clinic
Surname: Anamaria
Surname: bastea
First name: Mitre
First name: emin
Date of birth: 03.02.1983
Institution: Centrul Noro
Sex: ☐ male x female
☐ ☐ unknown
(assigned at birth)
Declaration of Consent Please Note
By signing this form, I declare that I have received comprehensive information Our panels are regularly updated to reflect current scientific research. It should
regarding the genetic background related to the disease in question, as well as the therefore be recognized that there is the possibility that the list of genes on the order
possibilities and limitations of molecular genetic testing. I understand that I have the form may have changed slightly (genes added or removed) by the time the sample is
right to withdraw my consent for genetic analyses. analyzed in the laboratory. By signing this form, the patient accepts that the list of
I have been informed, and agree, that my personal data and the data obtained in the genes analyzed may be slightly different from what is currently listed. When NGS is
analysis will be recorded, evaluated, or stored in a pseudonymized form in scientific utilized more than the requested genes might be sequenced for each sample.
databases, and that further, in accordance with data protection and medical All genes, including the complete mtDNA are sequenced when exome diagnostics
confidentiality, the request, or parts thereof, may be transmitted to a specialized is performed. The diagnostic evaluation is limited to variants in genes relevant to
cooperating laboratory. the provided phenotypic information. Correct family relationships are assumed
I consent to the re-evaluation of my test results within the data storage period. If for comparative exome analysis using data from several family members
significant alterations become apparent, my doctor will be informed by e-mail. (e.g. trio exome analysis).
I consent that in addition to the full genetic test as requested, the analysis can be I have been informed, and agree to the electronic storage, processing, use, and
expanded to all pathogenic and likely pathogenic variants (ACMG class 4 and 5) in genes transmission of all data collected by CeGaT GmbH. For more detailed information on
which are related to the indication described for the proband (if applicable, screen for data privacy as well as your rights please refer to [Link]/privacy-policy.
differential diagnosis).
This declaration of consent can be completely or partially withdrawn at any time.
I have had sufficient time to consider giving my consent.
If you do not check these boxes, your answer will be recorded as “No”.
I consent to the storage of my genetic material for additional tests and/or quality control x yes
☐ ☐ no
(for max. 10 years).
I consent to the storage of my test results beyond the time span of 10 years x yes
☐ ☐ no
(as required by German law).
I consent to the pseudonymous storage and use of surplus genetic material and/or test results x yes
☐ ☐ no
for scientific research and in scientific literature.
With regard to secondary findings, I would like to be informed: ☐x yes ☐ no
Genetic variation may sometimes be identified, which does not fit within the scope of the requested genetic analysis (so-called secondary findings). The reporting of these variants
is limited to pathogenic alterations (ACMG classes 4 and 5) within selected genes, for which a treatment or course of action exists for you or your family (according to the current
guidelines of the American College of Medical Genetics and Genomics; details on genes and associated diseases can be found at [Link]/acmg-genes). There is no claim
of a comprehensive analysis of this gene set. An absence of secondary findings cannot be used to indicate a reduced disease risk.
Targeted analysis of the ACMG genes according to current recommendations can be requested as “additional analyses”.
I, the referring physician, confirm that I am authorized to request genetic testing for the above-mentioned patient. For predictive testing, I confirm that I am authorized, and
that I have fulfilled the requirements, to request this testing.
If the patient did not sign this order form: I, the referring physician, confirm that the patient received genetic counseling and agrees with the genetic testing. The patient’s
consent has been obtained in writing. For minors, I declare that I have the consent of all legal guardians.
Order ID
Mitre Anamaria emin bastea 5896
Patient / Legal Guardian Physician
ᵪ ᵪ
Patient / Legal Guardian Physician
(Date, Signature) (Date, Signature)
CeGaT GmbH | Paul-Ehrlich-Str. 23 | 72076 Tübingen | Germany
Phone +49 7071 565 44-55 | Fax +49 7071 565 44-56 | info@[Link] | [Link] Ver. 2024.1.3
Powered by TCPDF ([Link])
