Jnetics on Campus at Bath University

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Name*

Title First Last

Date of Birth*

Day

Month

Year

Email (non-academic email address)*

Please use a personal email address, to ensure that you can keep your records in the future.

Mobile Phone*

Gender at birth:*

Female

Male

Marital Status*

Single

Married

Engaged

Divorced

Separated

Civil Partnership

Student ID number*

University*

Course*

What year of study are you in?*

Which secondary school did you attend?*

Addresses

Home Address*

Address Line 1 Address Line 2 City County Postcode Country

FAMILY HISTORY

Please note:

You may need to contact family members in order to give complete answers to these questions.

The information you provide enables us to give you the most appropriate risk assessment.

Ashkenazi refers to Jews who originated from Central or Eastern Europe.

Sephardi/Mizrahi refers to those who come from Spain/Portugal, Southern Europe, North Africa, Central & Western Asia and the Middle East.

Do you have at least one Jewish biological grandparent?*

Yes

Please count living or deceased grandparents.

Please speak to a member of the Jnetics team before proceeding with this form.

How many Ashkenazi Jewish grandparents do you have?*

Please count living and deceased grandparents.

How many Sephardi/Mizrahi Jewish grandparents do you have?*

Please count living and deceased grandparents.

What is/are the country/countries of origin of your Sephardi/Mizrahi grandparents?

Click here for a full list of the recessive disorders covered by our test.
A carrier is unaffected by the recessive disorder themselves but can pass the mutated gene onto their children.

Do you have any relatives who have/had any of the conditions we test for?*

Yes

Unknown

Please state the condition(s) and how you are related to the family member(s).

e.g. mother, half brother, father’s sister’s son.

Do you have relatives who are (healthy) carriers of any of the conditions we test for?*

Yes

Unknown

Please state the condition(s) and how you are related to the affected family member(s).

e.g. mother, half brother, father’s sister’s son

Please request a laboratory report or letter if any relatives are carriers or affected by any of the conditions on our panel so the Jnetics test is as accurate as possible.

Do you have a copy or does your GP/hospital/clinic have a relevant report/genetic results letter?

Yes

If YES, please scan and send a copy of this report to the CRGH admin team jnetics@crgh.co.uk and include a note of your name and date of birth

GP Details

Please provide us with your GP details, if you do not know the full details, please provide as much as you can.

A copy of your report and letter will be sent to your GP. If you are unable to provide your GP’s details, we cannot guarantee that they will receive a copy of the results.

NHS GP & Surgery (name and address, including postcode):*

GP Name Address Line 1 City County Postcode Country

Surgery Email:

If you are unable to provide their email address please provide as many details as you can in the field above. Without an email address we cannot guarantee that they will receive a copy of the results.

Please Read this Section Carefully

Screening involves providing a buccal cheek swab. In a small number of cases, we may have to request a second buccal cheek swab if the amount of DNA extracted is insufficient.
This test detects the vast majority of all genetic changes in the genes covered. However, this test, as with all genetic tests, cannot detect all possible changes.
Jnetics works in partnership with The Centre for Reproductive and Genetic Health (CRGH). Reports are delivered from the testing laboratory to the genetics counselling team at CRGH. The results, along with your booking information and consent forms, will be securely stored by CRGH. CRGH will retain this information within their patient database in line will all applicable regulation.
Test results are shared with you from CRGH via a secure portal 15 weeks after your appointment unless advised otherwise.

Agreements*

At the screening, we will be obtaining a DNA sample. Please read the below statements and select to indicate consent. You will have the opportunity to discuss any further questions at the screening.

I consent to being tested for carrier status for the 47 conditions on the Jnetics screening panel.

I give permission for my personal information to be securely shared with the trained Jnetics screening advisor who will conduct my consultation.

I give permission for my results to be shared by CRGH with other healthcare professionals in order to assist testing a relative..

I agree that my email address will be used for the communication of results.

I agree that the information on this form will be shared with CRGH and that they in turn will use this information to communicate the results to me, and your GP if applicable.

I understand that my registration details, consent form and results will be held securely by CRGH who will retain this information within their patient database in line will all applicable regulation.

Jnetics promise to always keep your details safe, and we will never sell or share your details; please see our Privacy Policy for more details.

Consent*

By accepting you confirm that all the information you have provided to us is true to the best of your knowledge and you agree to attend the appointment.*

Student Full Name*

Student Signature*

Consent

I agree to the privacy policy.

We would like to keep in touch and update you about the work we do and how you can support Jnetics. You can update your communication preferences at any time. I am happy to hear from Jnetics by:

Phone

SMS

Post

Comments

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FAQs