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Pre-Consultation Questionnaire

The purpose of the Genetic Consultation session is to help you decide whether you want to take a genetic test, SureMart, to find out whether you are at risk of passing on any genetic conditions to your children. In order to help you make this decision, it is helpful for our Clinical Genetic Service to review relevant information about you before your Consultation session. This will help us tailor the session to your specific needs.

This form will be sent to our Clinical Geneticist once you have booked your session, so that he/she can prepare for your meeting. The self-referral questionnaire is in 3 parts : Part A is for the Female partner, Part B is for the Male partner and Part C can be answered by either of you. Some fields are optional, however the more relevant information we have, the better we can guide you.

The cost of the consultation session is £70 for a 30-40 min consultation.

Contact Details
Email *
Contact Number *
A. Female Partner
Family Name *
First Name *
Date of Birth *
Would you describe yourself as healthy?: Yes No Prefer not to say
B. Male Partner
Family Name *
First Name *
Date of Birth *
Would you describe yourself as healthy?: Yes No Prefer not to say
C. Children
How many children? *
Male *:
Female *:
If you have given us any symptoms above
do your children show any of the symptoms that affect either of you?
Yes No N/A
Any Additional Information
Consent to the use of personal information
By signing this statement, you consent to sensitive information, such as information about your health, medical history and self-reported Information, such as race, ethnicity and other relevant medical information being submitted by you, in order for us to:
 
  • provide you with our Genetic Consultation Services
  • monitor and improve existing products or services that we offer, or to develop new products and services
 
We will not use your sensitive information without your consent unless: (i) the information has been anonymised or aggregated so that you cannot reasonably be identified as an individual; or (ii) a legal obligation requires us to use it in some way e.g. a court order requires us to disclose the information.

Consent to the transfer of your personal information
By agreeing to this document, you consent to the storing and processing of your personal information, including sensitive information, in the UK. Your personal information will be subjected to the laws of the country it is stored in. You also consent to your personal information, being transferred in the event of a business transition such as a merger acquisition by another company or other transactions or proceeding. Should such a situation occur, your information would be used as set out in any pre-existing Privacy Statement.

You may independently decide to disclose your information to third-party individuals such as friends, family, doctors, health care professionals, or any other individuals outside our Services, including through third-party services such as social networks. Always review the privacy policies of third-party services before you share your information.

We may share anonymised and aggregated information with third-parties; anonymised and aggregated information is any information that has been stripped of any identifiable information (e.g. name and contact details) and aggregated with information of others or anonymised so that you cannot reasonably be identified as an individual.

We will use such information and share it with third-parties for scientific and research purposes. We will NOT disclose your individual-level information unless we obtain explicit additional consent from you.

If you have any queries you can contact the MolMart Team at info@molmart.co.uk or send a letter to the postal address provided on our website (www.molmart.co.uk).

By Submitting, we confirm we voluntarily give consent for personal date to be stored and used as stated above.

Thank you.

After submitting this form, you will be given the option to book a 30-min appointment with our Clinical Geneticist. Please select the time and date carefully. We are unable to reschedule appointments or refund missed appointments.