Jnetics in Mainstream Schools Booking Form – Jnetics | Prevention and management of Jewish genetic disorders in the UK

Complete this form if:

You are 16 years old or above
You have at least one Jewish biological grandparent
You have discussed screening with your parents/guardian

Pupil Details

Please complete the details for the pupil being screened.

Name*

Title First Last

Please complete your full name as on your medical records.

Date of Birth (DD/MM/YYYY)*

Gender at birth:*

Male

Female

Marital Status:*

Address*

Street Address Address Line 2 City County Postcode Country

Student mobile number*

Student personal email address*

Please include the student's PERSONAL email address. Please do NOT use a school email address.

Which school do you attend?*

Did you attend the educational session at your school?*

Yes

Parent/Guardian mobile phone number

Parent/Guardian Email

Are you comfortable for your parents to receive a copy of your results?*

Yes

Please note your results will be sent to you via a secure portal. We need all the information on this booking form to set up your portal account. You will be notified by email when you have a message or your results are available in the portal.

Family History

You may need to contact family members to complete answers to these questions. The information you provide enables us to conduct 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 contact the office at students@jnetics.org or call 020 8158 5123 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.

If you have Sephardi/Mizrahi grandparents, what is their country of origin?

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

Yes

Unknown

Click here for a full list of the disorders covered by our test.

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

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 family member(s):*

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, before screening, 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, date of birth and date of screening.

NHS GP & Surgery

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 & Address

GP Name Address Line 1 City County Postcode Country

GP Email

Consent to ask parents

I don’t know my GP’s details, I give consent for you to contact my parent/guardian to obtain my GP’s details so my results can be shared with them after testing.

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

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.

Student Full Name*

Student Signature*

Name

This field is for validation purposes and should be left unchanged.

Recessive Carrier Testing

NHS Jewish BRCA Testing

FAQs

Jnetics in Non-Jewish Mainstream Schools

Jnetics is now pleased to offer screening to students with at least one biological Jewish grandparent at mainstream non-Jewish schools, following our successful educational Jewish assemblies.

Complete this form if:

Pupil Details

Please note your results will be sent to you via a secure portal. We need all the information on this booking form to set up your portal account. You will be notified by email when you have a message or your results are available in the portal.

Family History

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.

NHS GP & Surgery

PLEASE READ THIS SECTION CAREFULLY

Agreements

Contact us

More information

Recessive Carrier Testing #text-2403802506 { font-size: 1rem; }

NHS Jewish BRCA Testing #text-1623903346 { font-size: 1rem; line-height: 1; }

FAQs #text-186888635 { font-size: 1rem; line-height: 1; }

Jnetics in Non-Jewish Mainstream Schools

Jnetics is now pleased to offer screening to students with at least one biological Jewish grandparent at mainstream non-Jewish schools, following our successful educational Jewish assemblies.

Complete this form if:

Pupil Details

Please note your results will be sent to you via a secure portal. We need all the information on this booking form to set up your portal account. You will be notified by email when you have a message or your results are available in the portal.

Family History

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.

NHS GP & Surgery

PLEASE READ THIS SECTION CAREFULLY

Agreements

Recessive Carrier Testing

NHS Jewish BRCA Testing

FAQs