Patient Intake Form Δ
Genetic Counseling Information
Please enter the information below to assist with scheduling your genetic counseling session.
The information in this patient intake form is strictly for diagnosis purposes only. Oxy-Gen Laboratory does not sell or misuse any of the following information, none of this data is used for research purposes.
Which genetic test are you considering?
- Select Your Desired Genetic Screening - I'll wait for the genetic counselor to determine Cancer Screening (CGx) Carrier Screening Diabetes & Obesity Screening Hereditary Cardio Screening Parkinson's / Alzheimers / Dementia Screening Immunodeficiency Screening Pharmacogenetics (PGx)
Personal Information
Please enter your personal information below.
Gender Assigned at Birth
- Select Gender - Male Female
Race
- Select Race - White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Ashkenazi Jewish Other
Family & Personal Medical History
Genetic testing requires family and personal medical history in order to determine necessity of testing, please enter your family medical history below and answer to the best of your ability.
How many family members do you have with a history of genetic health issues?
- Select How Many Family Members - Nobody in my family has genetic health issues 1 2 3+
Personal Medical History
If you have ever had a history of genetic medical issues, please enter the information below. If not please skip this section.
Additional Medical Comments (If Applicable)
Family Member #1
If family member one has any genetic health issues, please enter the information below. If not please skip this section.
Race
- Select Race - White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Ashkenazi Jewish Other
Gender Assigned At Birth
- Select Gender - Male Female
Additional Medical Comments (If Applicable)
Family Member #2
If family member two has any genetic health issues, please enter the information below. If not please skip this section.
Race
- Select Race - White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Ashkenazi Jewish Other
Gender Assigned At Birth
- Select Gender - Male Female
Additional Medical Comments (If Applicable)
Family Member #3
If family member three has any genetic health issues, please enter the information below. If not please skip this section.
Race
- Select Race - White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Ashkenazi Jewish Other
Gender Assigned At Birth
- Select Gender - Male Female
Additional Medical Comments (If Applicable)
Insurance Information (If applicable)
If you're choosing to pay via self-pay you can skip this section, if not please enter your insurance information below.
Patient Referral
How did you find us? If you were not referred, please skip this section and finish the form below.
How did you hear about us?
- Select - Google Social Media Friend / Family Doctor / Primary Physician
Pre-Test Consultation Payment (Optional)
To schedule your pre-test consultation and to get started with your genetic screening process, you must first pay for your pre consult.
If you haven't paid already in the storefront for a specific panel and would like the genetic counselor to determine what test you need to run, you can click the link below.
After you submit this form and make your pre-test consultation payment, we will reach out with the time and date of your over the phone consultation.
Click here to pay for your pre-test consultation
Consent Agreement (Required)
Please acknowledge all of the following consent terms below by checking each box to submit your patient intake form.
Submit Patient Intake Form
