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Fragile X Consent Form Mobile App

The Fragile X Consent Form mobile app includes an informed consent and requisition for laboratory testing. Informed consent MUST be signed by patient, parent/legal guardian or legal next of kin. The app requests the following tests: Southern Blotting for FMR1 5’UTR CGG Repeat Expansion (“Fragile X Test”). By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet the requirements dictated by HIPAA.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Fragile X Consent Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Last Name:

  • Ico textbox

    First Name:

  • Ico dropdown

    Gender:

  • Ico date

    Date of Birth:

  • Ico multiline

    Address:

  • Ico textbox

    Phone Number:

  • Ico textbox

    CUMC MRN (Unit number):

  • Ico date

    Date Collected:

  • Ico time

    Time Collected:

  • Ico textbox

    Policy Holder’s Name:

  • Ico date

    Policy Holder’s Date of Birth:

  • Ico textbox

    Policy Holder’s Social Security Number

  • Ico dropdown

    Relationship to Patient:

  • Ico textbox

    Other:

  • Ico textbox

    Primary Insurance Carrier:

  • Ico textbox

    Policy Number:

  • Ico textbox

    Group Number:

  • Ico multiline

    Address of Policyholder’s Insurance:

  • Ico textbox

    Secondary Insurance Carrier:

  • Ico textbox

    Medicare #:

  • Ico textbox

    Medicaid #:

  • Ico date

    Date Collected:

  • Ico time

    Time Collected:

  • Ico statictext

    Type of Specimen: Whole blood in EDTA (“lavender top”)/Citrate delivered within 24-48 hours at r...

  • Ico checkbox

    Developmental delay

  • Ico textbox

    (specify)

  • Ico checkbox

    Other features of Fragile X syndrome

  • Ico textbox

    (specify)

  • ...and More!

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