Requisition Form - Non-İnvaziv Prenatal Test

Please place collection kit
barcode here.
Requisition Form
Lutfen Ornek Toplama Kiti Icerisinden
Cikan Barkodu Buraya Yapistiriniz
Test Istek Formu
1
2
PATIENT INFORMATION (Must be completed in English)
HASTA BILGILERI
ORDERING CLINICIAN (Must be completed in English)
ISTEKTE BULUNAN KURUM
Patient Name (Last, First):
Soyadi, Adi:
Organization (Clinic, Hospital, or Lab)
Patient ID:
Referans Numarasi:
Telephone:
Patient DOB:
Dogum Tarihi
Perinatal Genetics
Telefon
(DD
Gun
/MM
/YYYY
Ay
Yil
Perinatal Genetics
Telephone number of clinic
LIMS-ID
)
Ordering Clinician:
Patient Street Address:
Adresi
İstekte bulunan doktor:
City:
Country:
Ulke
Sehir
Telephone:
Telefon
Email:
Email
Was an egg donor or surrogate used?
Y
 N
Y
N
Y
N
Yumurta donoru veya tasiyici anne kullanildi mi?
Is this a multiple gestation pregnancy?
Cogul gebelik (ikiz, ucuz vs) var mi?
Is mother a known microdeletion carrier?
Anne bilinen bir mikrodelesyon için tasiyici mi?
Natera is not able to run this test for patients who have used an egg donor or
surrogate, or have a confirmed or suspected multiple gestation pregnancy
(including vanishing twins). The microdeletion panel will not return results for any
microdeletion the mother carries, and another form of testing should be considered.
Natera bu testi; yumurta donoru kullanmis gebelere, tasiyici annelik yapmakta olan gebelere ve de teyit
edilmis/suphelenilen cogul gebelere (kaybolan ikiz de dahil) uygulayamaz. Mikrodelesyon paneli,
annenin tasidigi herhangi bir mikrodelesyon var ise sonuc vermez. Bu durumda, baska bir testin
uygulanması dusunulmelidir.
Will you be submitting a father sample with this case? Y
N
Baba da ornek verecek mi?
If sample is not in the same box as the mother sample, it will not be processed.
*Eger babanin ornegi, annenin ornegi ile ayni kutuda gonderilmez ise isleme alinmaz!
If yes, provide name of father (Last, First):_________________________________
Evet ise, babanin ismi (Soyad, Ad olarak):
Gestational Age: ________
Hamilelik Haftasi
(weeks)
________ or
(days)
Due Date: (DD_____/MM_________/YYYY__________)
Tahmini Dogum
gun
hafta
Gun
Ay
Yil
Patient must be at least 9 weeks 0 days gestational age
*Gebelik en az 9 hafta + 0 gunluk olmalidir!
Maternal Weight: __________ Height: __________
Annenin kilosu
3
(kg)
kg
Boyu
(cm)
cm
SCREENING(S) REQUESTED (SELECT ONE PANEL)
Date of Blood Draw: (DD______/MM_____________/YYYY__________________)
Istenilen Tarama Testi (Sadece Bir Panel Seciniz)
KAN ALINMA TARIHI
OR
 THE PANORAMA™ PRENATAL PANEL
Ay
Yil
Genisletilmis Panorama Test (Kromozom, 13, 18, 21,X & Y, Triplodi, 22q11.2)
or
Temel Panorama Test (Kromozom 13, 18, 21,X &Y, Triploidi)
Gun
 THE PANORAMA™ EXTENDED PANEL
Screening chromosomes 13, 18, 21, X & Y, and Triploidy.
Screening chromosomes 13, 18, 21, X & Y, Triploidy, and the microdeletions selected below
Mikrodelesyonlar
 I want to screen for 22q11.2 Deletion syndrome.
DiGeorge sendromu (22q11.2 delesyonu) icin tarama yapılmasını istiyorum.
 I want to screen for 22q11.2, 1p36, Cri-du-chat, Angelman, & Prader-Willi.
DiGeorge, 1p36, Cri-du-chat, Angelman ve Prader-Willi sendromları icin tarama yapılmasını istiyorum.
Please select all appropriate clinical indications
Lutfen ilgili olan tum klinik bulgulari isaretleyiniz
 Advanced maternal age, 1st pregnancy
ileri anne yasi, ilk gebelik
 Advanced maternal age, not 1st pregnancy
ileri anne yasi, ilk gebelik degil
 Abnormal or positive serum screening
Anormal ya da pozitif serum tarama sonucu
 Possible hereditary disease affecting fetus
Fetusu etkileyebilecek ailesel hastalik
 Other specified antenatal screening
Diger antenatal taramalar
PAN-MD-REQ7.2-(2/27/14)MicroINTLB
 Other known or suspected abnormality in fetus affecting maternal management
Fetuste oldugu bilinen veya olmasindan suphe edilen diger anomaliler
 Unspecified antenatal screening
Belirtilmemis diger antenatal taramalar
 Pregnancy with poor reproductive history (prior pregnancy with an aneuploidy)
Problemli ureme gecmisi (daha onceki gebeliklerde down sendromu vb. anoploidili bebek öyküsü)
 Other: ________________________________________________________________________
Diger
Please Note: If insufficient genetic material (DNA) is obtained, a redraw may be requested.
ONEMLİ NOT: Eger yeterli genetik materyal (DNA) elde edilemezse, tekrar kan örneği istenilebilir.
201 Industrial Road, Suite 410 | San Carlos, CA 94070 | www.natera.com | 1-855-866-NIPT (6478) | Fax 1-650-730-2272