This page provides the consent wording used by TBMH-PGx for reference and later clinical onboarding. It is no longer part of the Stripe checkout flow.
This page remains a standalone policy reference only. Stripe checkout does not record consent on your behalf.
These items belong to the purchase of the test kit through Stripe and the downstream clinical onboarding process.
I understand that pharmacogenomic (PGx) testing is performed to assess how my genetic profile may influence my response to medicines. The purpose of this testing is to support safe and effective prescribing by providing my treating clinician with a clinical pharmacogenomic report that may inform medication selection and dosing.
I consent to Thompson Brain and Mind Healthcare (TBMH), a not-for-profit organisation, collecting and analysing my biological sample (for example, saliva, buccal swab, or blood) for pharmacogenomic testing. Testing may be conducted by TBMH or by partner laboratories accredited by the National Association of Testing Authorities (NATA) and operating in accordance with relevant ISO standards, including ISO 15189 for medical laboratory quality and competence.
I understand that the results of my PGx test will be used to generate a clinical report for my treating clinician. This report may include recommendations regarding medication choice or dosing. I acknowledge that PGx testing supports, but does not replace, clinical judgement, and that all treatment decisions remain the responsibility of my healthcare provider.
I understand that TBMH securely stores my biological sample and genetic data for up to ten years, or as otherwise required by law or laboratory accreditation standards. Storage and handling will comply with the Privacy Act 1988, the Australian Privacy Principles, and applicable NATA and ISO requirements.
I consent to my de-identified genetic material or data being used for quality assurance, validation, and method development activities necessary to maintain laboratory accuracy, safety, and accreditation. These activities will not involve the use of identifiable information.
I understand that my personal and genetic information will be handled securely and confidentially in accordance with the Privacy Act 1988 and the Australian Privacy Principles. Access to identifiable information will be restricted to authorised personnel only. De-identified data may be shared with approved collaborators or used in research and publications where I cannot be identified.
I acknowledge that participation in PGx testing is voluntary. I may withdraw my consent at any time before analysis has commenced, without affecting my access to care. If I withdraw after analysis has occurred, my stored sample may be destroyed upon request unless it must be retained for regulatory or accreditation purposes. Clinical reports already provided cannot be withdrawn.
I understand that PGx testing may not identify all genetic factors affecting medication response and that some results may have limited or uncertain clinical significance. PGx testing does not diagnose medical conditions, predict all treatment outcomes, or guarantee therapeutic benefit.
By providing this consent, I release and indemnify Thompson Brain and Mind Healthcare, its staff, affiliated laboratories, and research partners from liability arising from the interpretation or use of my pharmacogenomic results. I acknowledge that responsibility for applying the results rests with my treating clinician.
These remain optional choices and will be sent to you for later clinical onboarding.
My de-identified genetic and clinical data may be used in approved research projects aimed at improving pharmacogenomic knowledge, clinical guidelines, or health outcomes. Any research use would be subject to ethics approval and data would be de-identified prior to use.
My de-identified data may be linked with other approved health datasets (e.g., hospital admissions, prescription data, outcomes registries) to support population-level health research. Linkage would only be conducted by approved researchers under applicable data linkage legislation and with ethics oversight.
In the course of pharmacogenomic analysis, variants of potential clinical significance beyond the scope of the ordered test may occasionally be identified. I understand that TBMH's policy is to report clinically actionable incidental findings to my treating clinician, unless I opt out below. I have the right to specify that I do not wish to be informed of incidental findings.
This statement is relevant during clinical onboarding when a parent, guardian, or authorised carer is acting on behalf of a person under 18 years of age.
Where this consent form is being completed on behalf of a person under the age of 18 years, the signatory confirms: (a) they are the parent, legal guardian, or authorised carer of the patient; (b) they have the legal authority to consent on the patient's behalf; (c) where the patient is of sufficient maturity to understand the nature of the test, their assent has been sought and obtained; and (d) the decision to proceed is made in the best interests of the patient. If this section does not apply (i.e., the patient is 18 or older), please leave the checkbox below unchecked.