Informed consent for genomic testing and data use
Template. Must be reviewed by your legal counsel and ethics committee, and adapted to local law, before use with patients.
Patient name
Date of birth
Patient ID
What the test is
A sample (usually blood or saliva) is used to read part or all of your genetic material (DNA or RNA) to look for changes that may explain a health condition. The test requested for you is: ________________________________.
What the results can be
- A change that explains the condition is found.
- No explanation is found. This does not rule out a genetic cause.
- A change of uncertain meaning is found. It may become clearer later.
- Rarely, a finding unrelated to the reason for testing (a secondary finding), if you choose to receive these.
- Results can have meaning for blood relatives and can reveal unexpected family relationships.
Your choices (tick one box in each row)
| I agree to… | Yes | No |
|---|---|---|
| Genetic testing as described above | ☐ | ☐ |
| Receiving secondary findings that are medically actionable | ☐ | ☐ |
| Storage of my sample and data for re-analysis if knowledge improves | ☐ | ☐ |
| Use of my coded (de-identified) data for research | ☐ | ☐ |
| Sharing of de-identified data with scientific databases | ☐ | ☐ |
| Clinical photographs being stored in my record | ☐ | ☐ |
| Being contacted again about new findings or studies | ☐ | ☐ |
Your rights
- Taking part is voluntary. Saying no does not affect your care.
- You may withdraw any consent at any time by contacting info@tribro-omics.com or your clinician. Research use stops from that point; results already issued in your medical record are kept as the law requires.
- You may ask to see, correct or delete your personal data as provided by applicable data-protection law (for example the EU GDPR or India’s Digital Personal Data Protection Act).
- Your data is stored securely and is accessed only by authorised staff.
Signatures
Patient / parent / legal representative (name)
Relationship if not the patient
Signature
Date
Clinician who explained the test (name)
Signature
Date
Consent form version: 1.0
© Tribro-Omics · Informed consent for genomic testing and data use · Version 1.0 · 11 November 2026