PGT Informed Consent Form
Please review and complete the following to provide your informed consent for PGT.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Patient (if applicable)
Have you reviewed and understood the information provided about PGT?
*
Yes
No
Please indicate your understanding of the potential risks and limitations of PGT.
*
I understand the potential risks
I understand the limitations
I have discussed my questions with the provider
Please list any questions or concerns you would like to discuss.
Additional Comments (optional)
Submit Consent
Should be Empty: