Test Requisition & Informed Consent

BGI VISTA™ Carrier Screening · geneticlab, United Arab Emirates

1. Ordering clinician

Physician name
License / DHA-HAAD no.
Clinic / hospital
Emirate
Email for report
Phone

2. Patient

Full name
Date of birth
Emirates ID / MRN
Sex
Ethnicity / origin
Contact number

3. Partner (if tested)

Full name
Date of birth
Emirates ID / MRN
Contact number

4. Clinical indication

Preconception screening   Consanguineous union   Positive family history   IVF / PGT pathway
Gamete or embryo donor   Current pregnancy (gestational age: ______)   Other: ______________________

5. Panel selection

VISTA 10+ (11 conditions, 13 genes)   VISTA 170+ (172 conditions, 164 genes)   VISTA 1200+ (1,200+ genes)
Add-ons: Fragile X (FMR1)   Hemophilia A (F8)

6. Sample

Peripheral blood 2–5 mL EDTA   Saliva kit   Collection date/time: ____________________   Collected by: ____________________

7. Informed consent

I confirm that carrier screening has been explained to me. I understand that VISTA™ is a screening test and not a diagnostic test; it does not detect all variants or all genetic conditions, and a residual risk remains after a negative result. I understand that results may identify me as a carrier, may occasionally be uncertain, and may have implications for my partner, my children and other relatives. I consent to my sample being processed by BGI/geneticlab and my report being released to the ordering clinician named above. I understand I may request destruction of my residual sample at any time.

I consent to residual-sample storage for quality assurance   I decline residual-sample storage
Patient signature
Date
Partner signature (if tested)
Date
Clinician signature
Date