PATIENT CONSENT
I hereby voluntarily consent to test for the presence of gBRCA
mutation by providing blood sample.
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By agreeing to undergo this test, I acknowledge and confirm that:
1. I have understood the information provided to me by my Doctor
regarding the test;
2. This test will be performed by a third party testing laboratory which
will be solely responsible for the accuracy of the test results;
3. AstraZeneca does not perform any laboratory testing services and
is therefore not responsible or liable for my test results;
4. I will always consult my attending doctor about the test result prior
to initiation of therapy.
5. I understand that: (a) I can avail this Test at any other laboratory
other than the laboratories specified in this Test Coupon; and (b) If I
avail the Test at a different laboratory, the prices will be subject to
such laboratories’ pricing policies.
6. Aggregated data (without patient identifiers) may be analysed for
trend analysis and / or presented / published in congresses/journals.