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Important Note: <br />The Genetic Information Non -Discrimination Act of 2008 (GINA) prohibits <br />employers and other entities covered by GINA Title II from requesting or <br />requiring genetic information of an individual or family member of the <br />individual, except as specifically allowed by GINA. To comply with GINA, <br />we are asking that you do not provide any genetic information when <br />responding to this request for medical information. 'Genetic information' <br />includes an individual's family medical history, the results of an individual's <br />or family member's genetic tests, the fact that an individual or family <br />member sought or received genetic services, and genetic information of a <br />fetus carried by an individual or an individual's family member or an <br />embryo lawfully held by an individual or family member receiving assistive <br />reproductive services. <br />I have read the above and fully understand its contents in their entirety; I am <br />satisfied with the reason and purpose for which my permission is given. <br />My consent is valid for 180 days or shall terminate on <br />whichever comes first, and may be revoked by me at any time except for action <br />already taken. <br />Employee's Name (print) <br />Date <br />Employee's Signature Telephone No. <br />