Transcription of Non-invasive Prenatal Test Request Form
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Non-invasive Prenatal Test Request Form
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 requestedSINGLETONO ptional tests (no additional charge)Harmony Prenatal Test T21, T18, T13 Harmony Prenatal Test T21, T18, T13 + (additional charge)Fetal sex (based on presence or absence of Y chromosome) Monosomy XSex chromosome aneuploidy panelTWINO ptional tests (no additional charge)Harmony Prenatal Test T21, T18, T13 Fetal sex (can indicate either two females or at least one male)Is this a RE-COLLECTION? Previous Lab ID Staff ID/Location 2 x NIPT tube Date re-collected/ /Time re-collected:Re-collect PAY CATSGUNC linical informationREQUIREDALL fields must be completed for testing to note: Requested clinical information is essential for test accuracy. If any of the clinical information you provide below changes, please notify the laboratory immediately as this information is included in the test AGEE ither Weeks Days as at / / (date)or LMP EDC IVF / / (date)CONCEPTION DETAILSN aturalIVF (Patient egg) | Maternal age at egg retrieval yrsIVF (Donor egg) | Maternal age at egg retrieval yrsMATERNAL INFORMATIONM aternal weight (kg) Maternal height (cm) Female PregnantRequesting doctorName
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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