Genetic testing consent

M. E. Case number

Decedent name

Date of death

I hereby give my consent for the release of blood and/or tissue samples from the decedent named above, as I am the next-of-kin to the decedent.

These samples, currently being held at the Hennepin County Medical Examiner's Office, are to be released to a representative of a lab for the sole purpose of DNA banking or genetic studies.

This consent also permits the release of a final autopsy report to the Genetic Counselor.

This consent releases the sample and also gives permission to genetic testing results to be shared with HCME office.

NEXT OF KIN / LEGAL REPRESENTATIVE

Name

Relationship

Address

City

State

Zip Code

City, State, Zip Code

Phone number

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Phone number

Signature

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Date

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