DNA sample taken from patient: Yes/No
Consent form
Consent by parent or guardian for genetic testing to determine the cause of
hypoglycemia in a child less than 16 years old
Date:…………………………………………………………...
Child’s full name:……………………………………………..
Date of birth:…………………………………………………..
Parent or guardian’s full name:………………………………………..
I have given permission for a blood sample to be taken from my child to allow genetic
testing to be performed. I understand that this testing will be only for the purpose of
determining the cause of hypoglycaemia in my child or a member of my family. The
sample will not be used for any other purpose. The testing will be performed in the
molecular genetic laboratory, Peninsula Medical School, Exeter UK.
The details of the testing have been explained by …………………………………….
Signed …………………………………………………
Consent for genetic testing to determine the cause of hypoglycemia (patient)
Date:…………………………………………………………...
Name of the person:……………………………………………..
Date of birth:…………………………………………………..
I have given a blood sample to allow genetic testing to be performed on my blood. I
understand that this testing will be only for the purpose of determining the cause of
hypoglycaemia that affects myself or a member of my family. The sample will not be
used for any other purpose. The testing will be performed in the molecular genetic
laboratory, Peninsula Medical School, Exeter UK.
The details of the testing have been explained by …………………………………….
Signed …………………………………………………
If samples from other family members have been sent previously please give
details:.................................................................................................
.................……………………………………..
Consent for genetic testing to determine the cause of hypoglycemia (family
member, if applicable)
I have given a blood sample to allow genetic testing to be performed on my blood. I
understand that this testing will be only for the purpose of determining the cause of
hypoglycaemia that affects a member of my family. The sample will not be used for
any other purpose. The testing will be performed in the molecular genetic laboratory,
Peninsula Medical School, Exeter UK.
The details of the testing have been explained by …………………………………….
1) Name of the person:………………………………………
Date of birth:…………………………………………………
Relationship with the patient:………………………………..
Signed …………………………Date……………………….
2) Name of the person:………………………………………
Date of birth:…………………………………………………
Relationship with the patient:……………………………….
Signed …………………………Date……………………….
3) Name of the person:………………………………………
Date of birth:…………………………………………………
Relationship with the patient:……………………………….
Signed …………………………Date……………………….
4) Name of the person:………………………………………
Date of birth:…………………………………………………
Relationship with the patient:……………………………….
Signed …………………………Date…………………