Microsoft word - metforminconsent

AccuType™ Metformin
INFORMED CONSENT

1. What is Metformin? Metformin is the first line drug for both prevention and treatment of type 2 diabetes. Metformin is a substrate of drug transporter
protein, MATE1. Variation in this drug transporter protein is predictive of glucose lowering ef ect of metformin and may contribute to the variation of response
to metformin between individuals.

2. What is the purpose of this test and what are its limitations? The test predicts the patient’s therapeutic response to metformin by analyzing a DNA
variation in the gene coding for MATE1 protein. Genotyping patients with respect to this DNA variation may aid the physician in the use of metformin or
other available interventions. A negative result does not rule out the presence of other mutations in these or other genes, or other causes that may affect
metformin metabolism.
3. What is required to perform this test? You will be asked to provide 5 mL of blood, which is equal to about one tablespoon. DNA will be extracted from
this blood sample and tested. The only discomfort that you may feel is the stick of the needle in your arm. You may also experience a small bruise at the site
of the needle puncture. You will also be asked to provide information regarding your medical history, which is necessary for proper interpretation of your test
result. In the unlikely event that you should be injured in the course of being tested, your physician will provide any necessary medical care. However, you
would be expected to bear the cost of such medical care. Compensation will not be provided in the event of any injury.
4. Is there a cost for this test? This is a routine clinical laboratory test and the results may aid in your diagnosis; thus, you or your health insurer will be
billed for this procedure.
5. What will happen to the DNA once the test is complete? The original blood sample will be discarded at the end of the testing process or stored not
more than 60 days. The DNA will be retained for a minimum of 6 months. In some circumstances, a patient's DNA may be used anonymously as a negative
or positive control sample in future testing, but, in this circumstance, all identifiers will be removed prior to re-testing and the DNA sample and results
obtained will remain anonymous.
I understand and agree that my DNA remaining after testing may be stored for up to 6 months should additional testing be required. Please initial. 6. How will I obtain results from this test? DNA testing and interpretation of results are complex. The information from this test will be provided in the form
of a written report to your physician who will inform you of the results. The laboratory will not provide results directly to patients. Your physician may suggest
genetic counseling prior to performing this test or if your results are abnormal. To the extent permitted by law, all of your laboratory records and results are
confidential and shall not be disclosed without your written authorization.
Patient Attestation of Informed Consent:
My signature below indicates that I have received information about this test, AccuType™ Metformin, and that I have read and understood the material in
this document. I have been given a full opportunity to ask questions that I may have about the testing procedure and related issues. I agree to undergo this
testing.
Signature of Parent/Guardian if Patient is a minor
For the Physician:
As the referring physician, I understand the benefits and limitations of this study and have requested that the above-named patient be tested. I attest to the
fact that I have provided the patient with the information contained above and fully answered any questions. I believe that the patient understands the
information and is voluntarily signing this informed consent.
Signature of Physician/Health Care Professional Print Name of Physician/Health Care Professional Quest, Quest Diagnostics, the associated logo and all associated Quest Diagnostics marks are the trademarks of Quest Diagnostics. Copyright 2003 Quest Diagnostics Incorporated. All rights reserved. www.questdiagnostics.com. All other marks - ®' and ™'- are the property of their respective owner.

Source: http://www.specialtylabs.com/services/forms/download/consent/MetforminConsent.pdf