Thank you for making a reproductive genetic counseling appointment at the Mount Sinai Medical Center.

Transcription

1 Division of Medical Genetics Department of Genetics and Genomic Sciences Mailing address: One Gustave L. Levy Place, Box 1497 New York, NY Patient Address: 1428 Madison Avenue (at 99th Street) New York, NY Dear Patient: Thank you for making a reproductive genetic counseling appointment at the Mount Sinai Medical Center. Please complete the attached forms and bring them to your appointment. Please note that the family history questionnaire includes one page for the female member of the couple and one for the male member of the couple (if applicable). At the time of the genetic counseling session, we will review the information that you have provided and address all relevant issues. If a complex genetic counseling issue is identified, we will assist you with scheduling a follow-up genetic counseling session in order to thoroughly discuss that issue. For patients planning to have a CVS or amniocentesis procedure, please refer to the instructions specific to that procedure. Thank you very much for your cooperation. We look forward to working with you. Sincerely, Randi E. Zinberg, M.S. Julie McGlynn, M.S. Jane Robinowitz, M.S. Genetic Counselor Genetic Counselor Genetic Counselor Yara Kharbutli, M.S. Michelle Cahr, M.S. Leah Blanchard, M.S. Genetic Counselor Genetic Counselor Genetic Counselor

2 Do you (female partner) have a personal or family history of any of the following? When considering family members, please include your children, brothers, sisters, parents, aunts, uncles, cousins, and grandparents. *Please inform your genetic counselor/physician if you/your partner are adopted or if you are pregnant and a sperm/ovum donor was used to conceive the pregnancy. Personal/Family History of: No Yes (please specify) Down syndrome or other Chromosomal Abnormality Mental Retardation or Severe Developmental Delay Fragile X syndrome Congenital Spine or Brain Defect Congenital Heart Defect Congenital Kidney Defect Blindness/Deafness Cleft Lip and or Cleft Palate Other Serious Birth Defect(s) Muscular Dystrophy Cystic Fibrosis Significant family history of common conditions such as cancer or heart disease (i.e. people who were diagnosed at a young (<40) age or multiple affected family members) Bleeding Disorders (such as hemophilia) Inherited forms of anemia( such as Sickle Cell or Mediterranean/Cooley s Anemia) Skeletal Abnormalities / Dwarfism Neurological Disorders such as Huntington disease Other Genetic Disease Multiple Miscarriages Stillbirth or Infant/Child Death Are you related to your partner/spouse other than through marriage? ***What is your ethnicity/country(ies )of origin? Signature: Date:

3 Do you (male partner) have a personal or family history of any of the following? When considering family members, please include your children, brothers, sisters, parents, aunts, uncles, cousins, and grandparents. *Please inform your genetic counselor/physician if you/your partner are adopted or if you are pregnant and a sperm/ovum donor was used to conceive the pregnancy. Personal/Family History of: No Yes (please specify) Down syndrome or other Chromosomal Abnormality Mental Retardation or Severe Developmental Delay Fragile X syndrome Congenital Spine or Brain Defect Congenital Heart Defect Congenital Kidney Defect Blindness/Deafness Cleft Lip and or Cleft Palate Other Serious Birth Defect(s) Muscular Dystrophy Cystic Fibrosis Significant family history of common conditions such as cancer or heart disease (i.e. people who were diagnosed at a young (<40) age or multiple affected family members) Bleeding Disorders (such as hemophilia) Inherited forms of anemia( such as Sickle Cell or Mediterranean/Cooley s Anemia) Skeletal Abnormalities / Dwarfism Neurological Disorders such as Huntington disease Other Genetic Disease Multiple Miscarriages Stillbirth or Infant/Child Death Are you related to your partner/spouse other than through marriage? ***What is your ethnicity/country(ies )of origin? Signature: Date:

4 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (NOPP) By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the hospitals and the facilities listed at the beginning of this notice, and how I may obtain access to and control this information Patient Name Signature of Patient or Personal Representative Print Name of Patient or Personal Representative Date Description of Personal Representative s Authority I was not able to obtain the patient s acknowledgement of receipt of the NOPP upon registration because: The patient refused to sign despite good faith efforts The patient was unaccompanied and not alert and oriented The patient was unaccompanied and needed emergency care Other,( explain): Employee Signature: Employee Title: Print Name: Date: Acknowledgement subsequently obtained, (see above). MR-205 (Rev 5/04))

5 CONSENT FOR COMMUNICATION VIA (Provider-Patient) I,, hereby consent to have my physician,, communicate with me or members of his staff, where appropriate or other physicians, nurse practitioners and pharmacists via regarding the following aspects of my medical care and treatment: [test results, prescriptions, appointments, billing, etc.]. I understand that is not a confidential method of communication. I further understand that there is a risk that communications between my physician and me or members of my physician s office staff, or between my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any communications between my physician and me or members of his office staff, or between my physician and other physicians, nurse practitioners or pharmacists regarding my medical care and treatment will be printed out and made a part of my medical record. I understand that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on . Signature: Date: Address: _ MR-240 (9/03)