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Client Intake Form - Institutions
  Forms must be completed/ submitted prior to leaving our website

Forms must be completed/ submitted prior to leaving our website

1.  DATE:

1. DATE:

Date
2.  What is your reason for obtaining genetic information/referral?

2. What is your reason for obtaining genetic information/referral?


3.  Contact Individual /First Name, M.I.:

3. Contact Individual /First Name, M.I.:


4.  Contact Individual/Last Name

4. Contact Individual/Last Name


5.  Email Address(es)

5. Email Address(es)


6.  Mailing Address

6. Mailing Address


7.  Day Phone

7. Day Phone


8.  Evening Phone (if applicable)

8. Evening Phone (if applicable)


9.  Cell Phone

9. Cell Phone


13.  Please list here any restrictions concerning how and when to reach you

13. Please list here any restrictions concerning how and when to reach you


14.  Verifier

14. Verifier

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Discussions with a genetic counselor as offered by Genetic Laboratories and Genetic Testing Companies serve to provide key information for the understanding of genetic testing, although pedigree intake and record review may be focused to the results of genetic testing.  Although laboratory license and permit and genetic counselor certification and licensure where applicable, do not permit the practice of medicine, genetic counselors can provide explanation and direction to physicians and authorized medical professionals for the interpretation of the results of genetic testing.  Genetic counselors, upon physician waiver and in collaboration with ordering clinicians, can provide counseling on genetic testing and the meaning of test results. Comprehensive genetic counseling may be available through physicians who can provide genetic counseling within the scope of their practices as they choose and through genetic counselors within the scope of their practice. Please note that patient management and genetic counseling surrounding on-going prenatal or any diagnostic testing is best handled by Physicians, Maternal/Fetal and Pediatric Genetics specialists,  in conjunction with clinical services where they are available and in collaboration with genetic counselors and other genetic specialists. 

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