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1.  DATE:

1. DATE:

Date
2.  Name of Individual Making Request:

2. Name of Individual Making Request:


3.  For whom are you requesting that genetic research be done?

3. For whom are you requesting that genetic research be done?

(e.g. self, organization, physician, medical personnel, supervisor)

4.  Address:

4. Address:

What is the address of your facility?  At what address or location will patients be located at such time that you anticipate they speak with a genetic counselor through our service?  

5.  Details of Request

5. Details of Request

Please specify whether you are requesting service for patients at the time of appointment with your center, prior to the time of appointment or afterwards, and other details of encounter or contact which are important to know. 

6.  What is most important to you?

6. What is most important to you?

Please describe what you envision from a remote service.  What would be the perfect arrangment for your needs?   

7.  What types of patients, tests or conditions are involved?

7. What types of patients, tests or conditions are involved?

Feel free to explain anything about your service that it would be helpful to know. 

8.  What other options are you considering to meet your needs?

8. What other options are you considering to meet your needs?

Please discuss any other considerations you have for satisfying your staffing needs.  We can sometimes help you to budget by working with a point person from your center who may already be involved in your clinical processes.    If possible, please provide any general budget information here.  In doing so, we can be sure to include such in a program that does not exceed or fall short of your actual needs.  

9.  When do you need a service to START?

9. When do you need a service to START?


Also, please describe your current situation of Genetics or medical professionals who work in your clinic.  

What do you anticipate to be the role of our service with regards to any genetic testing coordination?  Is plebotomy and genetic test coordination available at your center directly?  



10.  Please provide your contact information

10. Please provide your contact information

Email and Phone number  

11.  Deliverable

11. Deliverable

What documentation will you require on patients that we service?  If you have any form or letter 'type' that your clinic or service now uses,  please feel free to fax (1-888-204-5975) or email to 1-888-260-6543.  
We will try to respond to all inquiries with useful information within one week
    of receipt of this form.  Thank you for  your consideration of Genetic Counseling Services 


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