Become a Patient
Thank you for your interest in Hoʻoilina Genomics Institute. This form helps us understand how we may be able to help. After reviewing your submission, we will contact you with information about next steps if appropriate. **Please do not include detailed medical records or sensitive health information in this initial inquiry.**
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
I am ...
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Seeking care for myself
Seeking care for my child
Family member/caregiver
Other
How did you hear about HGI?
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My physician
Family/Friend
Internet Search
Social Media
Another Healthcare Professional
Other
Please briefly describe what you are hoping to discuss or what prompted you to seek genetics care.
*
Previous Genetic Testing
To help us determine the most appropriate next steps and make the best use of everyone's time, please let us know if you or your family member has had any previous genetic testing or genetics evaluation. This information helps us review your request appropriately and avoid unnecessary duplicate testing or appointments.
Have you or your family member previously:
Seen a genetic counselor
Seen a medical geneticist
Had genetic testing
Iʻm not sure
None of the above
Has genetic testing already been performed?
Please Select
No
Yes
Iʻm not sure
If available, please briefly describe the testing performed or upload any previous genetic test reports. If you do not have copies, that's okay—we can discuss next steps after reviewing your inquiry.
Previous testing report upload
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Referring clinician (optional)
Referring clinician name:
Clinic/Hospital
How do you anticipate paying for your visit?
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I plan to use health insurance.
I anticipate paying directly (self-pay).
Iʻm not sure yet.
If you plan to use health insurance, which insurance company:
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HMSA
HMAA
UHA
Aetna
Cigna
UnitedHealthcare
Other
Iʻm not sure
Agreement
I understand this is an initial inquiry and does not schedule an appointment.
*
I understand.
I understand that providing complete information about previous genetics evaluations and testing helps Hoʻoilina Genomics Institute determine the most appropriate next steps and make the best use of everyone's time.
*
I understand.
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