Consent for PGx testing

Pharmacogenomics Informed Consent
Last Updated: Sep 24 2021

Pharmacogenetic testing is used to help understand why some people respond better than others to certain medications and why some people develop side effects while others do not. We work with a lab authorized under Clinical Laboratory Improvement Amendments (CLIA) and by all states to perform pharmacogenetic testing which is high-complexity testing. Pharmacogenetic testing involves the testing of DNA, RNA or other products. As the patient, I understand the following and freely give my consent to this genetic testing:

  •   You are providing a spit sample or buccal swab to examine pharmacogenetic information which may help your provider understand how you may respond to different medications.
  •   Pharmacogenetic testing may yield uninterpretable results for the following reasons: 1) buccal or spit sample contamination 2) insufficient sample collection 3) incomplete knowledge of the available genetic markers 4) technical reasons.
  •   The Genetic Information Nondiscrimination Act (GINA) generally protects you against discrimination based on your genetic information when it comes to health insurance and employment.
  •   Your results will be released to clinicians directly involved in your care. Because of the important implications, your results are confidential to the extent required by law, and may only be released to other medical professionals with your written consent.
  •   Pharmacogenetic testing is available free of charge as a part of our treatment platform. You are welcome to opt-out should you choose not to have this test taken.

Patient Consent
I have discussed and understand the risks and benefits of this test. By signing this form, I authorize the use of my sample to obtain results for tests indicated above. Furthermore, I authorize Prairie Health, Inc to retain, preserve, and use any data resulting from this test for scientific purposes, unless initialized below.


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