Consent form For genetic counselling of you or other family members We ask you to complete the consent form electronically on this website, please: www.datafabrikken.dk , here you enter the password: TZXA9HDY1NC2 . The link and the password can be used many times to several family members. The electronic consent form will automatically be transferred to us on a secure web connection. Consent form concerning ……(select ONLY one person per consent form ) Myself ☐ My child (0-15 years) ☐ Family no. – Important : ( Family no., a five-digit number you find in the letter from us/ may be disclosed by your relative.) Full name: Social Security No.: Who asked you to complete the consent form: (for instance, my brother, Hans Hansen) Which hospital (s) have you previously been treated at: Which disease(s) have you been treated for: Approximate year: See instructions on the following page for the questions below May we request information from …. - OUH and other hospitals/clinics for genetic counselling in your family Yes No ☐ ☐ May we provide information to…. - The Danish Pedigree Database - Departments of Clinical Genetics, Denmark - Relevant registers Yes No ☐ ☐ ☐ ☐ ☐ ☐ May we contact you…. - With questions or with information concerning results of research/analyses - In relation to future research where we would like to invite you to participate - In relation to medical examination or treatment relevant for you If yes, please inform us about your phone number: Yes No ☐ ☐ ☐ ☐ ☐ ☐ Date: Signature: (If you fill in for your child: please add relation, for instance, Hans Hansen, father)
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