{"id":4751,"date":"2023-02-22T19:39:09","date_gmt":"2023-02-22T19:39:09","guid":{"rendered":"https:\/\/drseq.com\/booking\/?page_id=4751"},"modified":"2023-02-23T20:02:30","modified_gmt":"2023-02-23T20:02:30","slug":"cardiac-death","status":"publish","type":"page","link":"https:\/\/drseq.com\/booking\/cardiac-death\/","title":{"rendered":"cardiac death"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"4751\" class=\"elementor elementor-4751\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a5e0f6a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a5e0f6a\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-302b5c4 ot-flex-column-vertical\" data-id=\"302b5c4\" 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.elementor-button>span{display:-webkit-box;display:-ms-flexbox;display:flex;-webkit-box-pack:center;-ms-flex-pack:center;justify-content:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center}.elementor-form .elementor-button .elementor-button-text{white-space:normal;-webkit-box-flex:0;-ms-flex-positive:0;flex-grow:0}.elementor-form .elementor-button svg{height:auto}.elementor-form .elementor-button .e-font-icon-svg{height:1em}<\/style>\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"4751\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"eac9ca5\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLAST NAME\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9249d24 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9249d24\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFIRST NAME\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9249d24]\" id=\"form-field-field_9249d24\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_9915350 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9915350\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDOB (MM\/DD\/YYYY)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_9915350]\" id=\"form-field-field_9915350\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_11af2a3 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_11af2a3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGENETIC SEX\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Male \" id=\"form-field-field_11af2a3-0\" name=\"form_fields[field_11af2a3]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_11af2a3-0\">Male <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"female\" id=\"form-field-field_11af2a3-1\" name=\"form_fields[field_11af2a3]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_11af2a3-1\">female<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unknown\" id=\"form-field-field_11af2a3-2\" name=\"form_fields[field_11af2a3]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_11af2a3-2\">Unknown<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_40fddb9 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_40fddb9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMED REC# \/ PATIENT IDENTIFIER\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_40fddb9]\" id=\"form-field-field_40fddb9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e6beed6 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e6beed6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tETHNICITY\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e6beed6]\" id=\"form-field-field_e6beed6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2995751 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2995751\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tADDRESS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2995751]\" id=\"form-field-field_2995751\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d1788e3 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d1788e3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCITY\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d1788e3]\" id=\"form-field-field_d1788e3\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0cd16fe elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0cd16fe\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSTATE \/ PROVINCE\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0cd16fe]\" id=\"form-field-field_0cd16fe\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_6a763b6 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6a763b6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPOSTAL CODE\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_6a763b6]\" id=\"form-field-field_6a763b6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_988c4ff elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_988c4ff\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCOUNTRY\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_988c4ff]\" id=\"form-field-field_988c4ff\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_dfd66a5 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dfd66a5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPHONE\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_dfd66a5]\" id=\"form-field-field_dfd66a5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_b3958be elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b3958be\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEMAIL\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_b3958be]\" id=\"form-field-field_b3958be\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_f76a233 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f76a233\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSAMPLE DRAW DATE(MM\/DD\/YYYY)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_f76a233]\" id=\"form-field-field_f76a233\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_122fb19 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_122fb19\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSAMPLE TYPE\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Blood    \" id=\"form-field-field_122fb19-0\" name=\"form_fields[field_122fb19]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_122fb19-0\">Blood    <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Buccal \" id=\"form-field-field_122fb19-1\" name=\"form_fields[field_122fb19]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_122fb19-1\">Buccal <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other:Extracted DNA &amp; DNA\" id=\"form-field-field_122fb19-2\" name=\"form_fields[field_122fb19]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_122fb19-2\">Other:Extracted DNA & DNA<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_7c8f948 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7c8f948\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSource\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Blood\" id=\"form-field-field_7c8f948-0\" name=\"form_fields[field_7c8f948]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_7c8f948-0\">Blood<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Buccal\" id=\"form-field-field_7c8f948-1\" name=\"form_fields[field_7c8f948]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_7c8f948-1\">Buccal<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tissue Clinical Exome\" id=\"form-field-field_7c8f948-2\" name=\"form_fields[field_7c8f948]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_7c8f948-2\">Tissue Clinical Exome<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-50 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-sm\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\" elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-aaa8575 ot-flex-column-vertical\" data-id=\"aaa8575\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2f4e333 elementor-section-full_width elementor-section-stretched elementor-section-height-default elementor-section-height-default\" data-id=\"2f4e333\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-wider\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-293f53b ot-flex-column-vertical\" data-id=\"293f53b\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e871e41 elementor-widget elementor-widget-text-editor\" data-id=\"e871e41\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.11.2 - 22-02-2023 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#818a91;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#818a91;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>I have read the Informed Consent document and I give permission to DrSeq to perform genetic testing as described. I also give permission for my specimen and clinical information to be used in de-identified studies at DrSeq and for publication, if appropriate. My name or other persona identifying information will not be used in or linked to the results of any studies and publications. More information is available at www.DrSeq.com<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-11e6973 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"11e6973\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1e10a22 ot-flex-column-vertical\" data-id=\"1e10a22\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-788d281 ot-flex-column-vertical\" data-id=\"788d281\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6b39e33 elementor-widget elementor-widget-heading\" data-id=\"6b39e33\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Family History<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fba32b7 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"fba32b7\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;50&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"4751\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"fba32b7\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFAMILY MEMBER 1 NAME\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9249d24 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9249d24\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRELATION TO PATIENT\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9249d24]\" id=\"form-field-field_9249d24\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6d3d7fc elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d3d7fc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGENETIC SEX\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Male\" id=\"form-field-field_6d3d7fc-0\" name=\"form_fields[field_6d3d7fc]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_6d3d7fc-0\">Male<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Female\" id=\"form-field-field_6d3d7fc-1\" name=\"form_fields[field_6d3d7fc]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_6d3d7fc-1\">Female<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unknown\" id=\"form-field-field_6d3d7fc-2\" name=\"form_fields[field_6d3d7fc]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_6d3d7fc-2\">Unknown<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8bd1ba0 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8bd1ba0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDIAGNOS IS AND \/ OR SYMPTOMS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8bd1ba0]\" id=\"form-field-field_8bd1ba0\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_a9d2be9 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a9d2be9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAGE OF ON SET\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_a9d2be9]\" id=\"form-field-field_a9d2be9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_39b5e03 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_39b5e03\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDOB (MM\/DD\/YYYY)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_39b5e03]\" id=\"form-field-field_39b5e03\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5259fdd elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5259fdd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFAMILY MEMBER 2 NAME\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5259fdd]\" id=\"form-field-field_5259fdd\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cdba323 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cdba323\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRELATION TO PATIENT\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cdba323]\" id=\"form-field-field_cdba323\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1a016b0 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1a016b0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGENETIC SEX\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Male\" id=\"form-field-field_1a016b0-0\" name=\"form_fields[field_1a016b0]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_1a016b0-0\">Male<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Female\" id=\"form-field-field_1a016b0-1\" name=\"form_fields[field_1a016b0]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_1a016b0-1\">Female<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Unknown\" id=\"form-field-field_1a016b0-2\" name=\"form_fields[field_1a016b0]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_1a016b0-2\">Unknown<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_681002f elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_681002f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAGE OF ON SET\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_681002f]\" id=\"form-field-field_681002f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1b00db9 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1b00db9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDIAGNOS IS AND \/ OR SYMPTOMS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1b00db9]\" id=\"form-field-field_1b00db9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_8db30dd elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8db30dd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDOB (MM\/DD\/YYYY)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_8db30dd]\" id=\"form-field-field_8db30dd\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-50 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-sm\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\" elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-0fa56db ot-flex-column-vertical\" data-id=\"0fa56db\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-30d8484 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"30d8484\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2bbd750 ot-flex-column-vertical\" data-id=\"2bbd750\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-86d2606 elementor-widget elementor-widget-heading\" data-id=\"86d2606\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">INSTRUCTIONS<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-05591c6 elementor-widget elementor-widget-text-editor\" data-id=\"05591c6\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ol><li>Complete the patient and provider information section.<\/li><li>\u00a0Read and sign the informed consent policy statement. The complete patient informed consent form for genetic testing<br \/>can be found on DrSeq.com. Signature from the provider on Page 1 of the TRF is required for all testing. Signature from<br \/>the patient is only required for billing purposes.<\/li><li>Write in the test name and indicate any relevant test options. Please call us if you have any questions.<\/li><li>Add-on any additional genes. Visit our website for our most updated list of 18,000+ available genes.<\/li><li>For Duo\/Trio testing, please complete the Family Samples section or submit a separate TRF for each sample.<\/li><li>Please visit DrSeq.com for specimen requirements.<br \/>Extracted DNA must extracted from a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by CAP and\/or CMS.<\/li><\/ol>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-63b8f08 elementor-section-full_width elementor-section-stretched elementor-section-height-default elementor-section-height-default\" data-id=\"63b8f08\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-wider\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-c065ed9 ot-flex-column-vertical\" data-id=\"c065ed9\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-fd6dbc5 elementor-align-center elementor-widget elementor-widget-button\" data-id=\"fd6dbc5\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a href=\"https:\/\/drseq.com\" class=\"elementor-button-link elementor-button elementor-size-sm\" role=\"button\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-text\">Home<\/span>\n\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>SCD TEST REQUISITION FORM I have read the Informed Consent document and I give permission to DrSeq to perform genetic testing as described. I also give permission for my specimen and clinical information to be used in de-identified studies at DrSeq and for publication, if appropriate. My name or other persona identifying information will not [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-4751","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/pages\/4751","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/comments?post=4751"}],"version-history":[{"count":79,"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/pages\/4751\/revisions"}],"predecessor-version":[{"id":4834,"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/pages\/4751\/revisions\/4834"}],"wp:attachment":[{"href":"https:\/\/drseq.com\/booking\/wp-json\/wp\/v2\/media?parent=4751"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}