Kingston General Hospital Clinical Genetics Laboratories
Authorization for release of samples from the genetics laboratory
Permission is hereby given to:
Molecular Hemostasis Laboratory - Genotyping – Queen’s University
(Name of individual or organization requesting sample)
to obtain a sample of blood / bone marrow / nucleic acid / tissue belonging to:
__________________________________
Name of patient
__________________________________
Date of birth
__________________________________
Unique Identifier
that is currently held in the Kingston General Hospital genetics laboratory. The sample is
released solely for the purpose of:
This consent may be withdrawn without penalty by the patient at any time.
_____________________________
Date
_____________________________
Date
_____________________________
Signature of patient, parent, guardian
or public trustee
_____________________________
Witness
April 2004
G:\GENERAL\GENETICS\MANUAL\DNA MANUAL\2004\CONSENT OF RELEASE OF SAMPLES.DOC