Hereditary Cancer Genetic Testing Consent

# Hereditary Cancer Genetic Testing Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Healthcare Organization / Genetics Program:** ___________ **Ordering Provider / Genetic Counselor:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ **Referring Diagnosis / Clinical Indication:** ___________ *E.g., personal history of breast cancer at age 42, strong family history of ovarian cancer, Ashkenazi Jewish ancestry, prior family member with identified BRCA1 pathogenic variant* --- ## 1. Purpose of Hereditary Cancer Genetic Testing This testing is intended to identify inherited (germline) variants in genes associated with significantly increased risk for specific cancers. A pathogenic or likely pathogenic variant in a hereditary cancer gene may affect medical management, surveillance protocols, and risk-reduction options for you and your biological family members. **Testing Panel Ordered:** ___________ **Specific Genes or Variant (if applicable):** ___________ **Laboratory:** ___________ **Specimen Type:** ___________ --- ## 2. Possible Test Results **(a) Pathogenic or Likely Pathogenic Variant (positive result):** A variant classified as disease-causing was identified. This significantly increases your lifetime risk for associated cancers and has direct implications for medical management and for biological relatives.