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MLH MSH Consent Form Mobile App

The MLH MSH 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: genetic testing. You can customize the amount of time the GoCanvas Smart Client on the mobile device can go without successfully authenticating against the GoCanvas servers.

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

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Take a peek inside the MLH MSH Consent Form Mobile App

Included Features

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Included Fields

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

  • Ico multiline

    Type of specimen:

  • Ico multiline

    REQUEST FOR MOLECULAR TESTING FOR (Specify all tests that are being ordered)

  • Ico statictext

    This form must be completely filled out and signed by patient, parent/legal guardian or legal nex...

  • Ico textbox

    REQUESTING PHYSICIAN, M.

  • Ico textbox

    Telephone No.

  • Ico textbox

    ID Code:

  • Ico multiline

    CONDITION (Purpose of Testing)

  • Ico statictext

    In accordance with State Law, the following has been discussed with the patient/legal guardian a...

  • Ico textbox

    Name of Person Obtaining Consent

  • Ico signature

    Signature:

  • Ico dropdown

    Title

  • Ico date

    Date:

  • Ico statictext

    Informed Consent/Advance Beneficiary Notice: Please read carefully and discuss with your ordering...

  • Ico statictext

    The condition stated above has been described to patient/legal guardian in detail.

  • Ico textbox

    2. The tests ordered above are for molecular genetic (DNA-based) tests to detect a mutation, or c...

  • Ico statictext

    The patient/legal guardian may wish to obtain genetic counseling prior to signing this consent f...

  • Ico statictext

    When DNA testing detects the most common disease-causing changes in a gene, the test result is h...

  • Ico statictext

    The results of the testing may 1) indicate a predisposition to have the above specified conditio...

  • Ico statictext

    A positive test result will help determine that a patient has the specified condition, or that t...

  • Ico statictext

    When DNA testing does not show a known genetic change, the chance that a person is a carrier or ...

  • Ico statictext

    In some families DNA testing may discover non-paternity (someone who is not the real father), or...

  • Ico statictext

    The results of the above tests become part of the patient's medical record.

  • Ico statictext

    Current State law prohibits discrimination by insurance carriers based on results of genetic tests.

  • Ico statictext

    10. (Initial One)

  • Ico signature

    I authorize

  • Ico signature

    I do NOT authorize the staff of the medical genetics staff of Hospital to make the results these ...

  • Ico statictext

    No tests other than the tests specifically authorized above will be performed on this sample, un...

  • Ico statictext

    Advanced Beneficiary Notice: Medicare/Insurance carriers may not pay for the testing, in which c...

  • ...and More!

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