Castle Medical, LLC
5700 Highlands Parkway Suite 100
Smyrna, GA 30082-5142
Phone 678-486-7340 Toll Free 855-822-7853
Fax 678-486-7350 Toll Free 855-922-7853
www.castlemedical.com
I,____________________________(patient’s name) hereby authorize Castle Medical, LLC to perform genetic testing for
______________________________ (test name/name of the associated disorder) as ordered by my/my dependent’s
physician to determine whether I, or members of my family carry a harmful mutation(s) which might be associated with
an increased risk for a disease or other medical condition. I understand that my/my dependent’s biological specimen (i.e.
blood/saliva/tissue) is required to conduct this test and I agree to provide the requested sample for testing.
I acknowledge that the following items have been explained to me:
1. The purpose, description, benefits, and risks of the test and an explanation of the disease this test is associated with.
2. That a positive test result means I might be predisposed to a specific disease and further testing might be
required to confirm the results. I understand that I need to consult with my genetic counselor or health care
provider to discuss my test results.
3. That a negative result implies that my chance of being affected with the specific disorder is reduced compared to
the general population. However, there is still a possibility that I may develop the disease due to non-hereditary
factors or due to other genetic factors not included in this test. Although every effort will be made to ensure the
accuracy and completeness of my result, the possibility of technical error cannot be ruled out. In addition, the
test may not be able to detect every possible risk factor of the disease, and the limitations of current testing
techology or lack of sufficient clinical information could also incfluence my risk for development of the disease.
I understand that I should discuss my results with my healthcare provider/physician before making any decision.
4. I understand that I may be asked about my family history and ethnic background in order to accurately
estimate my disease risk. I agree to provide this information if requested.
5. I was told that my biological specimen will be used only for the test requested. My specimen will not be used for
any other test or any research purposes. However, Castle Medical has the right to retain my specimen for
repetition or for further confirmation for a period of time as allowed by law.
6. I authorize the results to be released to my physician _________________________________ (name of the
physician) unless otherwise specified. I was told that my test results will be kept confidential and will be
disclosed to authorized personnel only.
7. My test results will be stored in a secure system by Castle Medical and will only be accessible to my physician,
genetic counselor, and other authorized persons.
Patient’s Acknowledgement:
By signing this document, I acknowledge that all of the above items were explained to me, that I fully understand
them, and I agree to genetic testing.
_______________________________________________________________________________________________
Patient’s Name Printed
Date
________________________________________________________________________________________________
Signature of Patient or Patient’s Legally Authorized Representative
Relationship to the Patient
Castle Medical, LLC
5700 Highlands Parkway Suite 100
Smyrna, GA 30082-5142
Phone 678-486-7340 Toll Free 855-822-7853
Fax 678-486-7350 Toll Free 855-922-7853
www.castlemedical.com
Physician/Healthcare Provider’s Acknowledgement:
By signing this document, the patient’s physician/healthcare provider endorses that he/she has explained the above
details of the test to the best of his/her ability. The patient has been given the opportunity to ask questions about this
consent and seek genetic counseling. The provider acknowledges that his or her patient has voluntarily decided to have the
test performed at Castle Medical, LLC.
__________________________________________________________________________________________________
Physician Signature
Date
__________________________________________________________________________________________________
Printed Name of Physician