Consent and Patient History Forms

The lab tests listed below require that a completed patient history and/or informed consent form be submitted to ARUP to perform and/or interpret patient results. For the ordered test, please print and fill out the required form(s), then submit with the test request form or electronic packing list.

Test numbers link to the test entry in the Laboratory Test Directory.

General Consent Forms for Physicians' Use
  ARUP Test Name Required Form
    English Español
Cytogenetic Testing Cytogenetic Testing
Biochemical Genetic Testing Biochemical Genetic Testing
Molecular Genetic Testing Molecular Genetic Testing
Genetic Testing Genetic Testing

 

Required Patient Consent/History Forms
Test # ARUP Test Name Required Form
2002387 Acetylcholinesterase and Fetal Hemoglobin Patient History for Prenatal Cytogenetics
0051265 Achondroplasia, Fetal Patient History for Fetal Molecular Testing
0051266 Achondroplasia, Mutation Patient History for Molecular Testing
0040033 Acylcarnitine Quantitative Profile, Plasma Patient History for Biochemical Genetics
0080427 Alpha Fetoprotein (Amniotic Fluid) with Reflex to Acetylcholinesterase Patient History for Prenatal Cytogenetics
0080137 Amino Acids Quantitative, CSF Patient History for Biochemical Genetics
0080710 Amino Acids Quantitative, Plasma Patient History for Biochemical Genetics
0080044 Amino Acids Quantitative, Urine Patient History for Biochemical Genetics
0051495 Alpha Thalassemia, HBA1 & HBA2, Gene Deletions Patient History for Hemoglobinopathy/
Thalassemia Testing
2001582 Alpha Thalassemia: HBA1 and HBA2, Sequencing Patient History for Hemoglobinopathy/
Thalassemia Testing
0051710 Alport Syndrome, X-linked (COL4A5) 3 Mutations Patient History for Alport Syndrome
2002394 Alport Syndrome, X-linked (COL4A5) Deletion/Duplication Patient History for Alport Syndrome
0051786 Alport Syndrome, X-linked (COL4A5) Sequencing Patient History for Alport Syndrome
2002398 Alport Syndrome, X-linked (COL4A5) Sequencing and Deletion/Duplication Patient History for Alport Syndrome
0051415 Ashkenazi Jewish Panel Patient History for Molecular Genetics
0050578 Beta Globin (HBB) Full-Gene Sequencing Patient History for Hemoglobinopathy/
Thalassemia Testing
0051421 Beta Globin Gene Mutations for HbS, HbC, & HbE by PCR Patient History for Hemoglobinopathy/
Thalassemia Testing
0051422 Beta Globin S,C,E, Fetal Patient History for Fetal Molecular Testing
0050388 Beta Globin Sequencing, Fetal Patient History for Fetal Molecular Testing
0051700 Biotinidase Deficiency (BTD) 5 Mutations Patient History for Biotinidase DNA Testing
0051730 Biotinidase Deficiency (BTD) Sequencing Patient History for Biotinidase DNA Testing
0051433 Bloom Syndrome, BLM Gene 2281del6/ins, 7 Mutation Patient History for Molecular Genetics
0051434 Bloom Syndrome, Fetal Patient History for Fetal Molecular Testing
0051453 Canavan Disease, ASPA Gene Mutations Patient History for Molecular Genetics
0051454 Canavan Disease, Fetal Patient History for Fetal Molecular Testing
0051682 Carnitine Deficiency, Primary (SLC22A5) Sequencing Patient History for Primary Carnitine Deficiency Testing
0080068 Carnitine, Free & Total (Includes Carnitine, Esterified) Patient History form Biochemical Genetics
0081110 Carnitine Panel Patient History form Biochemical Genetics
0080512 Carnitine Transport, Fibroblasts Patient History for Biochemical Genetics
2003164 Cerebral Cavernous Malformation (CCM1) Sequencing with Reflex to (CCM1, CCM2, and CCM3) Deletion/Duplication with Reflex to (CCM2) Sequencing and Reflex to (CCM3)Sequencing Patient History for CCM Testing
2003172 Cerebral Cavernous Malformation (CCM1, CCM2 and CCM3) Deletion/Duplication Patient History for CCM Testing
2003152 Cerebral Cavernous Malformation (CCM1) Sequencing Patient History for CCM Testing
2003156 Cerebral Cavernous Malformation (CCM2) Sequencing Patient History for CCM Testing
2003160 Cerebral Cavernous Malformation (CCM3) Sequencing Patient History for CCM Testing
2002293 Chromosome Analysis, Amniotic Fluid Patient History for Prenatal Cytogenetics
2002292 Chromosome Analysis, Bone Marrow Patient History for Cytogenetic (Chromosome) Studies
0097688 Chromosome Analysis, Breakage Syndrome Analysis Patient History for Cytogenetic (Chromosome) Studies
2002291 Chromosome Analysis, Chorionic Villus Patient History for Prenatal Cytogenetics
2002298 Chromosome Analysis, FISH-Interphase Patient History for Cytogenetic (Chromosome) Studies
2002299 Chromosome Analysis, FISH-Metaphase Patient History for Cytogenetic (Chromosome) Studies
2002290 Chromosome Analysis, Leukemic Blood Patient History for Cytogenetic (Chromosome) Studies
2002300 Chromosome Analysis, Lymph Node Patient History for Cytogenetic (Chromosome) Studies
2002289 Chromosome Analysis, Peripheral Blood Patient History for Cytogenetic (Chromosome) Studies
2002297 Chromosome Analysis, Prenatal FISH Patient History for Cytogenetic (Chromosome) Studies
2002288 Chromosome Analysis, Products of Conception Patient History for Prenatal Cytogenetics
2002287 Chromosome Analysis, Rule Out Mosaicism Patient History for Cytogenetic (Chromosome) Studies
0097677 Chromosome Analysis, Sister Chromatid Exchange Patient History for Cytogenetic (Chromosome) Studies
2002286 Chromosome Analysis, Skin Biopsy Patient History for Cytogenetic (Chromosome) Studies
2002296 Chromosome Analysis, Solid Tumor Patient History for Cytogenetic (Chromosome) Studies
2002297 Chromosome FISH, Prenatal Patient History for Prenatal Cytogenetics
0040203 Chorionic Villus, FISH Patient History for Prenatal Cytogenetics
0051374 Connexin 26 (GJB2), Sequencing Patient History for Hearing Loss
0051383 Connexin 26 (GJB2), 35delG Mutation Detection Patient History for Hearing Loss
2001956 Connexin 30 (GJB6) 2 Deletions Patient History for Hearing Loss
0050098 Cystic Fibrosis, 3199del6 Only
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 2946.		 Patient History for Cystic Fibrosis
0056003 Cystic Fibrosis (CFTR) 5T Mutation
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 2946.		 Patient History for Cystic Fibrosis
2001933 Cystic Fibrosis (CFTR) 32 Mutations Patient History for Cystic Fibrosis
2001970 Cystic Fibrosis (CFTR) 32 Mutations, Fetal Patient History for Fetal Molecular Testing
2001968 Cystic Fibrosis (CFTR) 32 Mutations with Reflex to Sequencing Patient History for Cystic Fibrosis
2001967 Cystic Fibrosis (CFTR) 32 Mutations with Reflex to Sequencing and Reflex to Deletion/Duplicaton Patient History for Cystic Fibrosis
2001969 Cystic Fibrosis, Atypical Patient History for Cystic Fibrosis
0056006 Cystic Fibrosis, Cis-Trans Patient History for Cystic Fibrosis
0051642 Cystic Fibrosis (CFTR) Deletion/Duplication Patient History for Cystic Fibrosis
0051110 Cystic Fibrosis (CFTR) Sequencing Patient History for Cystic Fibrosis
0051640 Cystic Fibrosis (CFTR) Sequencing with Reflex to Deletion/Duplication < Patient History for Cystic Fibrosis
0081106 Cystine Quantitative, Urine Patient History for Biochemical Genetics
0081105 Cystinuria Panel Patient History for Biochemical Genetics
0097720 Factor V Leiden (F5) R506Q Mutation Patient History for Molecular Genetics
0051463 Dysautonomia, Familial (IKBKAP) 2 Mutations Patient History for Molecular Genetics
0051464 Dysautonomia, Familial (IKBKAP) 2 Mutations, Fetal Patient History for Fetal Molecular Testing
2002658 Familial Mediterranean Fever (MEFV) Sequencing Patient History for FMF Testing
0051468 Fanconi Anemia Group C, FANCC Gene Mutations Patient History for Molecular Genetics
0051469 Fanconi Anemia Group C, FANCC Gene Mutations, Fetal Patient History for Fetal Molecular Testing
0082024 Fetal Fibronectin Patient History for Fetal Fibronectin
0051752 FG Syndrome, FGS1 (MED12) R961W Mutation Patient History for FG Syndrome
0040011 Fragile X Syndrome, DNA Testing Patient History for Molecular Genetics
0050543 Fragile X Syndrome, DNA Testing, Fetal Patient History for Fetal Molecular Testing
2002662 Freeman-Sheldon Syndrome (MYH3) Sequencing Exon 17 Patient History for Freeman-Sheldon Syndrome
0080125 Galactose-1-Phosphate Uridyltransferase Patient History for Galactosemia
0051176 Galactosemia (GALT) 9 Mutations Patient History for Galactosemia
0051175 Galactosemia (GALT) Enzyme Activity & 9 Mutations Patient History for Galactosemia
0051346 Galactosemia (GALT) Sequencing Patient History for Galactosemia
0051270 Galactosemia Mutation Panel, Fetal Patient History for Fetal Molecular Testing
0051438 Gaucher Disease (GBA) 8 Mutations Patient History for Molecular Genetics
0051439 Gaucher Disease (GBA) 8 Mutations, Fetal Patient History for Fetal Molecular Testing
0040201 Genomic Microarray Analysis for Constitutional Abnormalities Patient History for Cytogenetic (Chromosome) Studies
0040201 Genomic Microarray, UARRAY Chip Patient History for Cytogenetic (Chromosome) Studies
0051476 Glaucoma, Primary Congenital (CYP1B1) Sequencing Patient History for Primary Congenital Glaucoma
2002044 Hearing Loss, Nonsyndromic, Mitochondrial DNA 2 Mutations Patient History for Hearing Loss
2001992 Hearing Loss, Nonsyndromic Panel (GJB2) Sequencing, (GJB6) 2 Deletions, and Mitochondrial DNA 2 Mutations Patient History for Hearing Loss
0055656 Hemochromatosis Mutation Detection (C282Y, H63D, & S65C), Hereditary Patient History for Molecular Genetics
0050610 Hemoglobin Evaluation with Reflex to Electrophoresis and/or RBC Solubility Patient History for Hemoglobinopathy/
Thalassemia Testing
2001614 Hemophilia A (F8) 2 Inversions with Reflex to Sequencing and Reflex
to Deletion/Duplication		 Patient History for Hemophilia A or B Gene Testing
2001578 Hemophilia B (F9) Sequencing Patient History for Hemophilia A or B Gene Testing
0051348 Hereditary Hemorrhagic Telangiectasia Deletion & Duplication (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439.		 Patient History HHT Molecular Genetic Testing
Informed Consent HHT Deletion/Duplication
0051381 Hereditary Hemorrhagic Telangiectasia Full Gene Sequencing (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439.		 Patient History HHT Molecular Genetic Testing
Informed Consent HHT Full Gene Analysis (FGA)
0051382 Hereditary Hemorrhagic Telangiectasia Full Gene Analysis (HHT)
Contact ARUP genetic counselor prior to ordering at (800) 242-2787, ext. 3439.		 Patient History HHT Molecular Genetic Testing
Informed Consent HHT Full Gene Analysis (FGA)
0040018 Huntington Disease (HD) Mutation with Reflex to Southern Blot Informed Consent for Huntington Disease (HD) DNA Testing
0093484 Hypertrophic Cardiomyopathy Microarray, 11 Genes Informed Consent for HCM
0093482 Hypertrophic Cardiomyopathy, Familial Mutation Informed Consent for HCM
2002701 Loeys-Dietz Syndrome (TGFBR1 and TGFBR2) Sequencing and Deletion/Duplication Patient History for Loeys-Dietz Testing
2002705 Loeys-Dietz Syndrome (TGFBR1 and TGFBR2) Sequencing Patient History for Loeys-Dietz Testing
2002697 Loeys-Dietz Syndrome (TGFBR1 and TGFBR2) Deletion/Duplication Patient History for Loeys-Dietz Testing
0051650 Lynch Syndrome, HNPCC (MLH1) Sequencing & Deletion/Duplication Patient History for Lynch Syndrome/HNPCC Testing
0051654 Lynch Syndrome, HNPCC (MSH2) Sequencing & Deletion/Duplicationion Patient History for Lynch Syndrome/HNPCC Testing
0051656 Lynch Syndrome, HNPCC (MSH6) Sequencing & Deletion/Duplication Patient History for Lynch Syndrome/HNPCC Testing
0051737 Lynch Syndrome, HNPCC (PMS2) Sequencing & Deletion/Duplication Patient History for Lynch Syndrome/HNPCC Testing
2001728 Lynch Syndrome/HNPCC Deletion/Duplication Patient History for Lynch Syndrome/HNPCC Testing
2001971 Juvenile Polyposis (SMAD4) Sequencing and Deletion/Duplication Patient History for Juvenile Polyposis
0051510 Juvenile Polyposis (SMAD4) Sequencing Patient History for Juvenile Polyposis
2001976 Juvenile Polyposis (SMAD4) Deletion/Duplication Patient History for Juvenile Polyposis
0080434 Maternal Serum Screen, Alpha Fetoprotein (Only) Patient History for Maternal Serum Testing
0080108 Maternal Serum Screening, Alpha Fetoprotein, hCG & Estriol Patient History for Maternal Serum Testing
0080269 Maternal Serum Screening, Alpha Fetoprotein, hCG, Estriol, & Inhibin Patient History for Maternal Serum Testing
0081150 Maternal Serum Screening, First Trimester Patient History for Maternal Serum Testing
0081062 Maternal Serum Screening, Integrated Specimen #1 Patient History for Maternal Serum Testing
0081064 Maternal Serum Screening, Integrated Specimen #2 Patient History for Maternal Serum Testing
0081293 Maternal Screening, Sequential, Specimen #1 Patient History for Maternal Serum Testing
0081294 Maternal Screening, Sequential, Specimen #2 Patient History for Maternal Serum Testing
0051758 Medium Chain Acyl-CoA Dehydrogenase Deficiency (ACADM) Sequencing Patient History for MCAD Deficiency
0051205 Medium Chain Acyl-CoA Dehydrogenase Deficiency (ACADM) 2 Mutations Patient History for MCAD Deficiency
0055655 Methylenetetrahydrofolate Reductase Mutation Detection (Thermolabile form) (C677T & A1298C) Patient History for Molecular Genetics
2002366 Microarray Genomic, Fetal Patient History for Prenatal Cytogenetics
0051448 Mucolipidosis IV (MCOLN1) 2 Mutations Patient History for Molecular Genetics
0051449 Mucolipidosis IV (MCOLN1) 2 Mutations, Fetal Patient History for Fetal Molecular Testing
0081352 Mucopolysaccharides Electrophoresis & Quantitation, Urine (MPS SCREEN) Patient History for MPS Testing
0081357 Mucopolysaccharides, Quantitative, Urine Patient History for MPS Testing
0051390 Multiple Endocrine Neoplasia Type 2 (MEN2), RET Gene Mutations by Sequencing Patient History for Multiple Endocrine Neoplasia 2, (MEN2) RET Gene
0051492 Multiple Endocrine Neoplasia Type 2B (MEN2B), RET Gene M918T and A883F Mutations Patient History for Multiple Endocrine Neoplasia 2, (MEN2) RET Gene
2001952 Neurofibromatosis Type 1 (NF1) Deletion/Duplication Patient History for NF1/Legius Syndrome
0051459 Niemann-Pick Disease Type A, Fetal Patient History for Fetal Molecular Testing
0051459 Niemann-Pick Disease, SMPD1 Gene Mutations, Fetal Patient History for Fetal Molecular Testing
0051805 Noonan Syndrome (PTPN11) Sequencing Patient History for Noonan Syndrome
0099289 Organic Acids, Plasma Patient History for Biochemical Genetics
0098389 Organic Acids, Urine Patient History for Biochemical Genetics
2002016 Pancreatitis, Hereditary (PRSS1) Sequencing Patient History for Pancreatitis Testing
2002005 Pancreatitis, Idiopathic (CFTR, PRSS1, SPINK1) Sequencing Patient History for Pancreatitis Testing
2002012 Pancreatitis, Idiopathic (SPINK1) Sequencing Patient History for Pancreatitis Testing
0051308 Platelet Antigen Genotyping Panel Patient History for Fetal Molecular Testing
0056060 Prothrombin Nucleotide 20210 G/A Gene Mutation (Factor II) Patient History for Molecular Genetics
2002470 PTEN–Related Disorders, Sequencing and Deletion/Duplication Patient History for PTEN Testing
2002722 PTEN–Related Disorders, Sequencing Patient History for PTEN Testing
2002726 PTEN–Related Disorders, Deletion/Duplication Patient History for PTEN Testing
2002730 RASA1-Related Disorders (RASA1) Sequencing Patient History for RASA1 Gene Testing
0051614 Rett Syndrome (MECP2), Full Gene Analysis Patient History for Rett Syndrome (MECP2) Testing
0051378 Rett Syndrome (MECP2), Full Gene Sequencing Patient History for Rett Syndrome (MECP2) Testing
0051618 Rett Syndrome (MECP2), Deletion and Duplication Patient History for Rett Syndrome (MECP2) Testing
0050421 RhCc Antigen (RHCE) Genotyping Patient History for Fetal Molecular Testing
0051368 Rh Genotyping D Antigen (RhD positive/negative and RhD copy number) Patient History for Fetal Molecular Testing
0050423 RhEe Antigen (RHCE) Genotyping Patient History for Fetal Molecular Testing
0051428 Tay-Sachs (HEXA) 7 Mutations Patient History for Molecular Genetics
0051429 Tay-Sachs (HEXA) 7 Mutations, Fetal Patient History for Fetal Molecular Testing
0051508 Thanatophoric Dysplasia Type I/II Panel, Fetal Patient History for Fetal Molecular Testing
2002001 VLCAD Deficiency (ACADVL) Sequencing Patient History for VLCAD Deficiency
2002965 Von Hippel-Lindau (VHL) Sequencing and Deletion/Duplication Patient History for VHL Testing
2002970 Von Hippel-Lindau (VHL) Sequencing Patient History for VHL Testing
2002988 Von Hippel-Lindau (VHL) Deletion/Duplication Patient History for VHL Testing

 

 
All ARUP Sites:        www.aruplab.com     ·     www.arupconsult.com     ·     www.arup.utah.edu     ·     www.childx.org     ·     www.utahblood.org