Non-invasive Prenatal Test Request Form

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Non-invasive Prenatal Test | Request FormFOR THE DOCTORThis test should be requested by the doctor responsible for medical management of Non-invasive Prenatal detailsFirst name Surname Date of birth / / Sex Address Phone (mobile) Test/s requestedSINGLETONOptional tests (no additional charge)Harmony Prenatal Test T21, T18, T13Harmony Prenatal Test T21, T18, T13 + (additional charge)Fetal sex (based on presence or absence of Y chromosome) Monosomy XSex chromosome aneuploidy panelTWINOptional tests (no additional charge)Harmony Prenatal Test T21, T18, T13Fetal sex (can indicate either two females or at least one male)Is this a RE-COLLECTION?

Non-invasive Prenatal Test Information for patients Purpose The primary purpose of Harmony is to screen for common chromosome disorders which can affect the health of a baby, i.e. Down syndrome (trisomy

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