Dr.

Kashif Bashir
Molecular Genetics/Cancer Genetics Lab, Dept of Zoology
The University of Lahore, Sargodha Campus
Annexure-I
Lab Ref No---------------- Date----------------------

Consent Performa for Collection of Blood Samples

Sample: Blood (O+ve)

Name--------------Muhammad--------------Father’s/Husband Name------------------------------

Age-----------------8 years------------------- Gender----------------Male----------------------------

Education-------------------------------------- Residence----------------------------------------------

Address---------------------------------------------------------------------------------------------------

Smoking Status------------------------------------------------------------------------------------------

Occupation------------------------------------------- Ethnicity/cast-----------------------------------

Contact number (Optional) ---------------------------------------

Disease History--------------------------------

Treatment:

Treatment Time------------------------- Any other Disease--------------------------

Surgery------------------- Family History-----------------------

Angioplasty-------------------- Any other treatment----------------------