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BIOCHEMICAL GENETICS LABORATORY
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BIOCHEMICAL GENETICS LABORATORY

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  • 1. University of Colorado at Denver and PATIENT NAME: Health Sciences Center, DATE OF BIRTH: Anschutz Medical Campus FEMALE □ MALE □ BIOCHEMICAL HOSPITAL NAME: GENETICS ADDRESS: LABORATORY Department of Pediatrics PHONE: FAX: Bldg. RC-1 North, Room P18- 4403C PHYSICIAN: 12800 East 19th Avenue COLLECTION DATE: TIME: Aurora, CO 80045 I REQUEST PRENATAL DIAGNOSIS FOR: Phone: (303)724-3826 Fax: (303)724-3827 (GENETIC CONDITION) http://www.uchsc.edu/bglab Prenatal Diagnosis Consent Form I give my consent to have my fetus’ sample sent to the UCHSC Biochemical Genetics Laboratory for biochemical genetic testing for the genetic condition named above. I understand the tests that will be performed are specific only for the genetic condition named above. My signature below constitutes my acknowledgement that the principles, benefits, risks and limitations of this biochemical genetic testing have been explained to my satisfaction by a physician/genetic counselor, and I have had my questions answered. I further understand that any disputes that arise in relation to the testing shall be governed by the laws, rules and regulations of the State of Colorado, as are now in effect or as may be later amended or modified without reference to the choice of law or rules of any state. I do now submit to the exclusive jurisdiction and venue of any court having subject matter jurisdiction located in the City and County of Denver, State of Colorado, including the United States District Court for the District of Colorado, in the event of any litigation concerning the testing and regardless of where this consent is executed or where I reside. Signature of Patient or Legal Guardian: (date) Printed Name of Legal Guardian: Relationship to Patient: Physician/Genetic Counselor: I have explained this biochemical genetic testing and its limitations to the patient or legal guardian and answered all questions. Signature: Date:

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