MHLA, A Nursing Corporation

Andrena McGroarty, PMHNP-BC, MSN, RN

Pharmacogenomic Consult Consent

You are being evaluated today because you are:

  • experiencing lower than desired medication response and/or unwanted side effects,
  • taking multiple medications due to medical comorbidities and want to be aware of compounding interactions, or
  • because you/your child is younger than 18 years old with concerns about efficacy, tolerability and effective dosing, or
  • because a medication or dosage change is being considered by your provider

I would like to be tested for the following categories:

MHLA, A Nursing Corporation

Andrena McGroarty, PMHNP-BC, MSN, RN

______initial. Psychotropic

______initial. ADHD

______initial. Analgesic

______initial. MTHFR

MHLA, A Nursing Corporation

Andrena McGroarty, PMHNP-BC, MSN, RN

______initial. I understand that the test completed today may identify certain genetic variations and that medications are metabolized to varying degrees by more than one pathway.

______initial. I understand that pharmacogenomic tests are predictions based on information about the specific genetic variations being tested and that the clinician interpreting these results cannot say with 100% certainty what will happen with an individual patient.

______initial. I understand that the test results do not incorporate or make allowances for the other factors in a patient’s life related to the disease condition or to the individual that may also affect their response to treatment.

______initial. I agree to return once my results are complete for appropriate consultationbefore a report will be generated and sent to collaborating clinician.

Follow up:

A copy of your results and a consultation report will be provided to a clinician of your choice for ongoing care. If you do not have a clinician, an appropriate referral will be provided.

Assessment takes place in two parts;Sample collection and Evaluation Result review

It may take up to two weeks for reports to be completed and released.

Fee:

______initial. Diagnostic Evaluation and Consultation Fee = $125

(Fee is included in cost of care for MHLA, Inc. established medication management patients)

ACKNOWLEDGEMENT FORM

I hereby acknowledge and agree:

1. That I have received and read a copy of the Pharmacogenomic Consult Consentand agree to abide by this policy.

  1. That I will comply with the rules and regulations outlined in this policy.
  1. That this original acknowledgement will be placed in my patient record.
  1. That I have received the Notice of Privacy Practices from MHLA, Inc., or was made aware of its location on my clinician’s website and in the practice waiting room.

______

Name of Patient

______

Patient or Guardian signatureDate

______

Clinician signature: Andrena McGroarty, PMHNP-BC, MSN, RNDate