CLINIC NAME CLINIC ID REFERRING CLINICIAN PHONE FAX EMAIL ADDRESS CITY POST CODE COUNTRY CLINICAL AND TEST DETAILS NAME SURNAME DATE OF BIRTH (DD/MM/YY) ID PHONE EMAIL ADDRESS CITY POST CODE COUNTRY PATIENT INFORMATION REFERRAL INFORMATION AFFIX BARCODE LABEL — SIF HERE I hereby grant consent for my referral doctor for the collection and transport of a blood sample to NIPD Genetics laboratories. I also grant permission to NIPD Genetics to use this blood sample for the test requested on this form. I attest that I have read, or have had read to me, the Patient Informed Consent and that I understand it. I have had the opportunity to have counseling about the VERACITY test and to discuss with my referral doctor any aspect of this consent form including the benefits, risks and limitations of the VERACITY test, as well as the reasons for performing the test and availability of alternative testing options to my satisfaction. I agree that my referral doctor collects my personal and clinical details such as is needed to complete the sample information form and that such details are provided to NIPD Genetics for the purposes of performing the VERACITY test. I affirm that all information provided is true to the best of my knowledge and that I will not hold NIPD Genetics responsible for any consequences as a result of untrue or inaccurate information. I authorize NIPD Genetics to code, store and use leftover sample and test data for quality improvement and/or research purposes. I do not authorize NIPD Genetics to store and use my coded sample and test data as described above. PATIENT CONSENT CLINICIAN ATTESTATION I certify that the patient has been counseled about the test and informed of the content of the informed consent including the benefits, risks, and limitations of the VERACITY test, and have obtained informed consent from the patient for performing the VERACITY test. I attest the need to perform the VERACITY test to determine the risk for trisomies of 13,18,21, and upon request aneuploidies of X,Y, select microdeletions (DiGeorge, 1p36 deletion, Smith-Magenis, Wolf Hirschhorn) and fetal gender as part of the patient’s medical care. PATIENT SIGNATURE DATE CLINICIAN SIGNATURE DATE FOR LABORATORY USE ONLY ORDER NUMBER LAB ID NUMBER KIT LOT NUMBER COMMENTS Neas Engomis 31, Nicosia, 2409 Cyprus Phone: +357 22266888 Fax: +357 22266899 Web: http://www.nipd.com Email: [email protected]SAMPLE INFORMATION FORM CLINICIAN COMMENTS TICK ONLY ONE BOX BELOW FOR SINGLETON PREGNANCIES TICK APPROPRIATE BOX & ADD COMMENTS PATIENT/FAMILY HISTORY ABNORMAL ULTRASOUND ADVANCED MATERNAL AGE SERUM SCREEN RISK OTHER REQUESTED TEST TEST INDICATIONS T21 RISK SCORE: 1 in COLLECTION DATE (DD/MM/YY) TEST INFORMATION REDRAW TEST: YES NO TRISOMIES 13, 18, 21 TRISOMIES 13, 18, 21; PRESENCE OF Y TRISOMIES 13, 18, 21; PRESENCE OF Y; ANEUPLOIDIES X, Y TRISOMIES 13, 18, 21; PRESENCE OF Y; ANEUPLOIDIES X, Y; MICRODELETIONS FOR TWIN/VANISHED TWIN PREGNANCIES TRISOMIES 13, 18, 21 TRISOMIES 13, 18, 21; PRESENCE OF Y TRISOMIES 13, 18, 21; PRESENCE OF Y; MICRODELETIONS T18 RISK SCORE: 1 in T13 RISK SCORE: 1 in GESTATIONAL AGE (WEEK + DAY) HEIGHT (CM) WEIGHT (KG) MATERNAL INFORMATION CLINICAL INFORMATION COMPLETE ALL SECTIONS BELOW IVF PREGNANCY: YES NO SELF DONOR AGE AT EGG RETRIEVAL IVF INFORMATION SURROGATE: YES NO IF IVF, EGG USED: 1 FETUS MONOCHORIONIC TWIN DICHORIONIC TWIN NUMBER OF FETUSES 1 FETUS – VANISHED TWIN 2 FETUSES Collect 4 weeks after the vanishing event RECEIVED BY DATE & TIME OF RECEIPT(DD/MM/YY HH:MM)
2
Embed
PATIENT INFORMATION REFERRAL INFORMATION - nipt.gr
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
CLINIC NAME CLINIC ID
REFERRING CLINICIAN
PHONE FAX EMAIL
ADDRESS
CITY POST CODE COUNTRY
CLINICAL AND TEST DETAILS
NAME SURNAME
DATE OF BIRTH (DD/MM/YY) ID
PHONE EMAIL
ADDRESS
CITY POST CODE COUNTRY
PATIENT INFORMATION REFERRAL INFORMATION
AFFIX BARCODE LABEL — SIF
HERE
I hereby grant consent for my referral doctor for the collection and transport of a blood sample to NIPD Genetics laboratories. I also grant permission to NIPD Genetics to use this blood sample for the test requested on this form. I attest that I have read, or have had read to me, the Patient Informed Consent and that I understand it. I have had the opportunity to have counseling about the VERACITY test and to discuss with my referral doctor any aspect of this consent form including the benefits, risks and limitations of the VERACITY test, as well as the reasons for performing the test and availability of alternative testing options to my satisfaction.I agree that my referral doctor collects my personal and clinical details such as is needed to complete the sample information form and that such details are provided to NIPD Genetics for the purposes of performing the VERACITY test. I affirm that all information provided is true to the best of my knowledge and that I will not hold NIPD Genetics responsible for any consequences as a result of untrue or inaccurate information.I authorize NIPD Genetics to code, store and use leftover sample and test data for quality improvement and/or research purposes.
I do not authorize NIPD Genetics to store and use my coded sample and test data as described above.
PATIENT CONSENT
CLINICIAN ATTESTATION
I certify that the patient has been counseled about the test and informed of the content of the informed consent including the benefits, risks, and limitations of the VERACITY test, and have obtained informed consent from the patient for performing the VERACITY test.I attest the need to perform the VERACITY test to determine the risk for trisomies of 13,18,21, and upon request aneuploidies of X,Y, select microdeletions (DiGeorge, 1p36 deletion, Smith-Magenis, Wolf Hirschhorn) and fetal gender as part of the patient’s medical care.
PATIENT SIGNATURE DATE
CLINICIAN SIGNATURE DATE
FOR LABORATORY USE ONLYORDER NUMBER LAB ID NUMBER KIT LOT NUMBER