Obstetrics Counseling Form printable pdf download

Obstetrics Counseling Form

OBSTETRICS COUNSELING FORM

PLEASE PRINT, SIGN, AND BRING THIS PAGE TO YOUR PRENATAL VISIT.

I have read and understand the information regarding the following testing:

1. I agree to prenatal lab work which includes HIV testing. Other tests may be indicated depending on

your particular case.

Signature: ______________________________________________ Date: _______________

2. Cystic Fibrosis screening

Yes, I desire testing. Signature: ____________________________________ Date: _______________

No, I decline testing. Signature: ___________________________________ Date: _______________

3. Nuchal translucency/PAPP-A testing

Yes, I desire testing. Signature: ____________________________________ Date: _______________

No, I decline testing. Signature: ___________________________________ Date: _______________

4. Quad Screen

Yes, I desire testing. Signature: ____________________________________ Date: _______________

No, I decline testing. Signature: ___________________________________ Date: _______________

5. Third trimester HIV testing

Yes, I desire testing. Signature: ____________________________________ Date: _______________

No, I decline testing. Signature: ___________________________________ Date: _______________

Obstetrics Counseling Form