Consent and Payment Form

(To be accompanied by a referral form)

Patient Information

Laboratory testing

The presence or absence of a specific gene mutation has been identified as a predictor of drug response. Testing for gene mutations prior to treatment ensures that the patient receives a drug that has the potential to work for them.

***Patient Consent***

I understand that laboratory testing on my tissue is part of a clinical workup for my condition and the testing to be undertaken has been explained to me by the requesting clinician. I give permission for my tissue to be used for the following laboratory tests(s):

Payment Required *

Samples will not be processed unless payment has been confirmed.

*This is the current cost of testing for the panels listed above ONLY. Please contact the laboratory for the cost of any “other” tests required.

Payment Method

Internet Banking Details (Please use SURNAME and DOB as reference)
Bank: ASB
Account: IGENZ Ltd T/A DNA Diagnostics
Account details: 12-3109-0145960-00

Visa and Mastercard logos