CONFIDENTIAL INFORMED CONSENT & CLIENT INFORMATION FORM FOR GENETIC TESTING

By providing my information and signing below, I hereby consent to participate in nutrition-focused genetic testing offered by NucleoGenex.

No current genetic screening is capable of fully predicting the outcome for any of the conditions included in this screening. The results of this screening should only be taken as an indication of a predisposition to a condition. An increased risk does not indicate that an individual has an associated condition, or even that they will develop it in their lifetime. These results only indicate that an individual is statistically more likely to develop the condition as compared to an individual lacking the genetic variants. Conversely, a decreased risk is not a guarantee that this individual will not develop the condition in their lifetime. These results only indicate that an individual is statistically less likely to develop the condition.
This genetic test operates by determining the sequence of DNA at locations known to contribute to the development of a disease or condition. The nutritional products, the guidance levels assigned by NucleoGenex are up-to-date, but are subject to change with advancements in the field and the release of new published information.
Similar to the vast majority of genetic testing available, this is a laboratory-developed test (LDT) and is not approved by the United States Food and Drug Administration (FDA). Results from this test should not be used as the sole evidence of diagnosis for any disease or condition.
This test does not detect polymorphisms other than those listed in the report results. Accordingly, the results of this screening may not detect every known genetic variant that is associated with the disease or condition that is the subject of the screening.
The genetic testing offered by NucleoGenex is considered to be the best available at the time. This test is performed in a CAP accredited and CLIA certified facility, however, genetic testing is complex in nature and a small chance of error always exists when performing complex testing. I will not hold NucleoGenex liable in the event that such an error occurs.
I understand that certain diseases or conditions are multifactorial in nature and may not be directly attributed to a single genetic cause. I understand that environmental factors and lifestyle choices are important considerations when determining one's risk for developing a multifactorial disease or condition.
I understand that my sample will be used for genetic testing as authorized by my consent. NucleoGenex utilizes a CLIA certified laboratory which destroys processed DNA samples after a minimum of 90 days. The laboratory retains DNA testing data for 7 years and non-processed DNA samples for up to 3 years. This retention policy enables the laboratory to later test my non-processed DNA sample for future panels and products offered by NucleoGenex while avoiding the inconvenience of re-swabbing. I understand and expressly consent to this policy and process.
I further understand and agree that NucleoGenex may utilize my DNA testing data and other personal information to offer me new products, services, and/or recommendations.

Customer Information

First Name *

Middle Name *

Last Name *

Birth Date *

Sex *

Phone *

Email Address *

Street Address *

Address Line 2

Select Country * State *

City *

Zip Code *