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Forms must be completed/ submitted prior to leaving our website

Forms must be completed/ submitted prior to leaving our website

Please note that every item on this form requires an entry.  Please type x or any letter, where you do not have an answer.  Also, insurance information is not necessary for self pay or laboratory referred patients.  
1.  Today's Date (Month/Day/Year)

1. Today's Date (Month/Day/Year)


2.  What is your reason for obtaining genetic information/referral?

2. What is your reason for obtaining genetic information/referral?


3.  Have you scheduled your appointment yet?

3. Have you scheduled your appointment yet?

Appointments can be booked at www.geneticcounselingservices.com  On our homepage, go to:  Book Your Appointment Here  

4.  First Name, M.I.:

4. First Name, M.I.:


5.  Last Name

5. Last Name


6.  What name do you prefer that we use in our communication?

6. What name do you prefer that we use in our communication?

(Mary Alice, Mrs. Smith, Mimi or other nickname )

7.  Date of Birth (Month/Day/Year)

7. Date of Birth (Month/Day/Year)


11.  Address

11. Address


12.  Previous Address

12. Previous Address


13.  Day Phone (xxx-xxx-xxxx)

13. Day Phone (xxx-xxx-xxxx)


14.  Evening Phone (xxx-xxx-xxxx)

14. Evening Phone (xxx-xxx-xxxx)


15.  Cell Phone (xxx-xxx-xxxx)

15. Cell Phone (xxx-xxx-xxxx)


16.  Cell phone number and carrier for text confirmation 48 h. before

16. Cell phone number and carrier for text confirmation 48 h. before

( Ex: 111-111-1111. Verizon) Please type NO if you do not wish to receive a text confirmation 48 hours prior to your appointment.  

17.  Best Number to call for your Telephone Consultation

17. Best Number to call for your Telephone Consultation

Please include area code.  You will be called at this number at the time of your scheduled appointment unless you notify us otherwise in advance.  

18.  Email Address(es)

18. Email Address(es)


22.  Please list here any restrictions concerning how and when to reach you

22. Please list here any restrictions concerning how and when to reach you


23.  Primary Ins. Policy Holder's Name  (if other than self)

23. Primary Ins. Policy Holder's Name (if other than self)

Insurance information is not necessary for self-pay patients. 

24.  Primary Ins. Policy Holder's D.O.B.

24. Primary Ins. Policy Holder's D.O.B.


25.  Primary Ins. Co. Name and Address (needed for testing auth.)

25. Primary Ins. Co. Name and Address (needed for testing auth.)


26.  Primary Ins. Policy Holder's Employer / Address

26. Primary Ins. Policy Holder's Employer / Address


27.  Patient ID # /  Group #

27. Patient ID # / Group #


29.  If yes, please fill out the following:

29. If yes, please fill out the following:

Secondary Ins. Policy Holder

Secondary Ins. Policy Holder


Secondary Ins. Policy Holder's D.O.B.

Secondary Ins. Policy Holder's D.O.B.


30.  Secondary Ins.Co. Name and Address

30. Secondary Ins.Co. Name and Address


31.  Secondary Ins. Policy Holder's Employer / Address

31. Secondary Ins. Policy Holder's Employer / Address


Secondary Ins. ID# / Group #

Secondary Ins. ID# / Group #


32.  Primary Care Physician's Name and Address

32. Primary Care Physician's Name and Address


33.  Primary Care Physician's Phone #

33. Primary Care Physician's Phone #


34.  Primary Care Physician's Fax #

34. Primary Care Physician's Fax #


35.  Referring Physician's Name and Address

35. Referring Physician's Name and Address


36.  Referring Physician's Phone #

36. Referring Physician's Phone #


37.  Referring Physician's Fax #

37. Referring Physician's Fax #


38.  Other Specialist Name and Address

38. Other Specialist Name and Address


39.  Area of Specialty (eg. Oncologist, Hematologist, etc.)

39. Area of Specialty (eg. Oncologist, Hematologist, etc.)


40.  Specialist's Phone #

40. Specialist's Phone #


41.  Specialist's Fax #

41. Specialist's Fax #


42.  List Physicians to receive copy of Genetics Consultation

42. List Physicians to receive copy of Genetics Consultation

We recommend that you list your Primary Care Provider and Referring Physician.

44.  Consent for Genetic Counseling

44. Consent for Genetic Counseling

I hereby request genetic counseling from a board certified genetic counselor through Genetic Counseling Services.  I understand that this service will comprise of taking an in depth personal and family medical history and analysis of potential risk for certain hereditary conditions and diseases.  Based on the information that I provide, information about diagnostic or predispositional genetic testing for which I may be indicated will be offered for my physican and me to consider.   I acknowledge that the genetic counselor does not diagnose, provide treatment, or order any type of test, that my physician is solely responsible for providing these services.   By typing my name below, I acknowledge the above statements.    

45.  Signature of Minor here for consent of genetic counseling

45. Signature of Minor here for consent of genetic counseling

Parent or Guardian must also sign above

46.  Consent for Release or Request Information to/from Physicians and Insurance Company

46. Consent for Release or Request Information to/from Physicians and Insurance Company

I hereby authorize the staff of Genetic Counseling Services to release and/or obtain medical information  to/from  referring physicians and my insurance carriers who are currently or potentially involved in my medical care. I understand that this information will be treated in a strictly confidential manner and will be used only for the purpose of securing medical and/or surgical treatments deemed necessary by my medical care providers and for payment of my care.  I authorize my insurance provider to submit payments directly to Genetic Counseling Services for genetic counseling and I understand that I am ultimately responsible for my bill  and any portion of it that is not covered by my insurance, unless otherwise discussed.   By typing my name below,  I acknowledge the above statements. 

47.  Minor signature here for consent to release information

47. Minor signature here for consent to release information

Parent or Guardian must also sign above

48.  Verifier

48. Verifier

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