Get Mcl - Hereditary Hemorrhagic Telangiectasia (hht) Gene Testing Patient Information - Mc1235-155

Filling out the MCL - Hereditary Hemorrhagic Telangiectasia (HHT) Gene Testing Patient Information form is an important step in the genetic testing process. This guide will help you complete the form accurately and efficiently, ensuring all necessary information is provided for proper interpretation of test results.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access the MCL - Hereditary Hemorrhagic Telangiectasia (HHT) Gene Testing Patient Information form.
2. Enter the patient information, including the patient's full name (last, first, and middle), birth date in the format mm-dd-yyyy, and gender, selecting from the options provided.
3. Provide the referring provider's name along with their phone number. Include a fax number, ensuring it complies with applicable HIPAA regulations.
4. Indicate the reason for referral and check all relevant clinical history boxes, such as the presence of telangiectasia, nosebleeds, juvenile polyps, or visceral AVMs. Fill in details as necessary.
5. Complete the ethnic background section by selecting the appropriate category and specifying countries of origin if available.
6. Provide family history details, indicating if other relatives are known to be affected, if they have had molecular genetic testing for HHT, and including any pertinent details regarding known mutations.
7. If applicable, include the informed consent statement for New York State patients regarding genetic testing.
8. Once all sections are completed, review the information for accuracy and completeness before saving changes, downloading, or printing the form.

Complete your form online to facilitate genetic testing and receive accurate results.