Informed Consent For DNA Banking Form

 

I, ____________________________________, request and authorize the Molecular Genetics Laboratory at the Center for Human and Molecular Genetics to keep the DNA obtained from me.

In the event that no DNA is obtained from the specimen submitted, I understand that another specimen will be requested.

I understand that:

  • any testing of this sample will be done only with my specific written consent

  • this sample will only be released with my written consent.

  • the Center will not be held responsible for diagnostic testing results obtained with this specimen by other facilities

  • the Center will keep the DNA for the useful life of the sample

  • while the Center does not plan to stop operation of the DNA banking facility, should any change affecting the storage of samples occur, the Center will try to notify each donor to determine what to do with that sample.

  • although the Center will use all reasonable efforts to safely store the sample, the sample could be ruined by equipment or power failure, flood or other catastrophe.

  • the sample may be unusable because protocols in use now for storing DNA may be inappropriate for a genetic test that may be developed in the future.

My signature below acknowledges my voluntary participation in DNA banking.

Signature (patient): ________________________________________________________
Or
Signature (legal guardian): ___________________________________________________

Witnessed by: _________________________________________________________

Date: _________________________________________________________

 

 

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