The Jnetics Clinic

Recessive Screening Clinic - Extra Gene

This form is for a participant that has previously registered for Jnetics Recessive Carrier Screening and has been approved to be screened for any additional gene(s).

Name:(Required)

Title First Last

Date of Birth:(Required)

Email:(Required)

Number of participants to be screened:

Second Participant Name:(Required)

Title First Last

Second Participant Date of Birth:(Required)

Second Participant Email:(Required)

Have you already registered for Jnetics' carrier screening?(Required)

Yes

We require that you sign up for the Jnetics Clinic before we can perform any additional screening.

Have you had a consultation with our Genetic Counsellor?(Required)

Yes

We require that you have a consultation with our Genetic Counsellor before we can perform any additional screening. Please contact us to discuss this request: Email: screening@jnetics.org WhatsApp: +44 7493 054 126 Call: 0208 158 5123

Number of extra genes to be analysed:(Required)

Name of additional gene(s) to be screened:(Required)

Please enter the name of the gene(s), not the condition. This should match that on the report you shared with our Genetic Counsellor.

Full Name:(Required)

Signature:(Required)

Second Participant Full Name:(Required)

Second Participant Signature:(Required)

Total

Payment:(Required)

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