Gknowmix Test Request


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Client Details

Service Options

Please select type
Service Required?
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Health Care Practitioner Information

Referring Health Professional email address
Referring Healthcare Practitioner
Contact Number
Participating HP Email Address
Copy to Participating HP
Participating HP Contact Number
Client Email Address
Client Title
Client First Name
Client Surname
Address
Post Code
Date of Birth
Age
Ethnicity
Gender
Client Contact Number
Gknowmix Reference
Family Number / Index (Office Use)
Specimen Identifier / Barcode

Consent

I hereby give consent to services requested, guarantee payment and verify that all information is correct
If a genetic test is performed, the laboratory is allowed to release the diagnostic codes to my medical aid if necessary
My genetic material and clinical information may be included in in a database for research, related to the services requested, without revealing my identity
After completion of the genetic test my genetic material should be handled as follows:

Medical Aid Information

Medical aid
Plan Option
Member Number
Reference / Authorization No
ICD-10 Code
Medical Aid Motivation
Include Medical Aid Motivation in Quote

Additional Counselling Information

Counselling Required For
Age of Disease Diagnosis
Genetic mutation/change identified
Family history of selected medical condition
Number of 1st degree relatives affected
Number of 2nd degree relatives affected
Ancestry
Notes