Pharmacogenomic Test form

Patient Consent and Order Form

Please fill out the form to get started with testing

First Name

Last Name

Date of Birth

Please check the box indicating your agreement with the following: Required

No past medical history of bone marrow transplant or liver transplant

Terms of Use: By checking here, you are stating you have received and agree with the MyTraitRx Terms of Use. You understand this test may not answer questions regarding certain medication side effects

Patient Consent for Testing: You are consenting to testing and consultation by a pharmacist with MyTraitRx. "Testing" may include but not be limited to: interviewing you, reivew of your lab test, performing tests and colling specifmens for outside labs to test

By checking here, you affirm that you have carefully read, understand, and voluntarily agree to this Patient Consent in its entirety and have had the opportunity to discuss your condition, concerns, and the above procedure before signing this Patient Consent

Payment Policy: By checking here you understand and agree that full payment for servcies rendered are due and expected to be paid in full at the time of MyTraitRx service. You further understand that it is your responsibility to file for any reimbursement from your medical insurance provider. For your convenience, MyTraitRx accepts payment through PayPal, debit cards, or all major credit cards

Consent to Electronic Communication: We may use the e-mail address you provide to facilitate communication with you. We are dedicated to protecting your privacy and use secure email systems for notification of genetic testing results. By checking here, you authorize us and consent to communication with you via e-mail. Please read our Privacy Policy to learn more about our electronic communication

If you are the parent or guardian of a minor child, you affirm that there are no court orders now in effect that prohibit you from signing this Patient Consent form on behalf of your minor child. You are providing your consent to MyTraitRx and by doing so authorize genetic testing by Lauren Cherrier, PharmD. You understand that MyTraitRx will explain conditions foreseeable risks, and genetic testing results before any recommendations are provided

Initials

I declare that the info I’ve provided is accurate & complete

Address- Where to send the test

Pharmacogenomic test, consultation and optional medication list review $429

Provider Order/Rx

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Patient Consent and Order Form

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