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Prenatal Genetic Screening Lab Requisition

Prenatal Genetic Screening Laboratory RequisitionPrenatal Biochemistry LaboratoryPlease visit for additional copies of the Requisition and other InformationSURNAMEFIRST NAME & MIDDLE INITIALPERSONAL HEALTH NUMBER / CARECARDDATE OF BIRTH: YY MM DDFor Completion by Collection LaboratoryDATE AND TIME OF COLLECTIONCOLLECTION CENTRE / FACILITY CODECOLLECTOR S INITIALSC ollect 5 mL SST tube, centrifuge, transport to the C&W lab with 96 hours @ 4 C. For alternate instructions contact COMPLETION BY C&W LABORATORYS creen Requested (Choose One Only)SCREENTIMINGS erum Integrated Prenatal Screen (SIPS) Part 1 9 13+6 wks Part 2 14 20+6 wks Quad Screen 14 20+6 wks Maternal Serum AFP Only See Prenatal Genetic Screening Guideline for indications for ordering 15 20+6 wksOrdering Doctor / Midwife / Nurse PractitionerNAME MSP PRACTITIONER #ADDRESS TELEPHONESIGNATURE DATECopy Results toNAME MSP PRACTITIONER #ADDRESS TELEPHONENAME MSP PRACTITIONER #ADDRESS

Prenatal Genetic Screening Laboratory Requisition Prenatal Biochemistry Laboratory Please visit www.bcprenatalscreening.ca for additional copies of the requisition …

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  Screening, Parental, Genetic, Prenatal genetic screening

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