Test Requisition Form/Informed Consent
Frontside: The blue (left) side of the form is for doctors/healthcare providers and the green (right) side of the form is for the parent/family to complete.
Backside: The back contains the informed consent, which families should review with the ordering provider or with a Lineagen genetic counselor by telephone.
Family Forms for NextStepDx PLUS
To be completed by each family member (typically biological mother and father) who will be providing a buccal (cheek) swab sample to assist the interpretation of the patient’s
NextStepDx PLUS results. If needed, Lineagen can coordinate sample collection.
Lineagen’s licensed and certified genetic counselors are available at 801-931-6191 to answer questions about NextStepDx PLUS.