GENETIC SERVICES FORM | Rare Diseases SA

GENETIC SERVICES

Genetic counsellors are healthcare professionals who have specialised education at the Masters degree level in both genetics and counselling.

Genetic counsellors provide risk assessment, education and support to individuals and families affected by, or are at risk of, genetic disorders. Genetic counsellors interpret genetic testing, provide short-term psychosocial counselling, facilitate necessary referrals and serve as patient advocates.

Genetic Services Registration

Patient's First Name

Patient's Last Name

Patient's Email

Patient's Contact Number

Patients' Address

Patient's Birthday

Patient's Gender

Patient's Home language

Patient's Race

Age of Patient

What is your Medical Diagnosis?

Background information and reasons to want to start counselling?

Are you a member of a dedicated support group?

Yes

No, but would like to be

Would you like us to place you in touch with other patients with similiar disorders/Symptoms?

Yes

Is there any other information you feel we should be aware of?

Full name of Guardian (in case of minor) / Emergency Contact

Relationship to Patient

Email for Next of Kin

Contact number of Next of Kin

Full name of Patient's primary treating doctor?

Physical Address of treating doctor

Email of treating doctor

Contact Number of treating doctor

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Thank you for you registering as a Patient with RDSA.