Print Form
* Required
* Name:
(surname)
(given)
PRENATAL SCREENING for Dow n syndrome,
·
·
* Date of Birth:
Trisomy 18 and Open Neural Tube Defects
yyyy
mm
dd
To obtain NT ultrasound at Mount Sinai Hospital [MSH]: Referring
* Health Card #:
healthcare provider must FAX a standard referral form to 416-586-8384 to
book NT ultrasound at MSH. Women should go to the 3rd floor Ontario Power
* Address:
Generation Bldg, 700 University Ave, Toronto for the scheduled test.
* Postal Code:
Phone: (
)
External Blood Collection Centres: Send samples & requisition to Pathology
Find NT standard referral form & this requisition online at :
& Lab Medicine, Room 6-308, 600 University Ave, Toronto, ON M5G 1X5
Tel: 416-586-8510 / 877-586-8511
Fax: 416-586-4640
Accurate information is necessary for a valid interpretation.
•
Patients with a family history of open neural tube defects or Down syndrome should be referred to a genetics centre.
•
Prenatal screening requires patient education and should proceed only with the informed choice of the patient.
Test Requested (choose one only)
Clinical Information
Racial origin:
kg
Integrated Prenatal Screen
White
Weight: __________________
lbs
Part 1
[11w – 13w6d] [CRL 41-84 mm]
Black
Part 2
[15w – 18w6d] _____________________________
Asian
Last Menstrual Period (LMP):
nd
Suggested week to go for 2
sample
First Nation Aboriginal
__________ _______ ______
Other: ______________
yyyy
mm
dd
First Trimester Screen
[11w – 13w6d] [CRL 41-84 mm]
(Ultrasound dating is preferred – fill in below
(Specify)
)
Maternal Serum Screen
[15w – 20w6d]
Smoked cigarettes in this
Patient on insulin prior to pregnancy?
Maternal Serum AFP only
[15w – 20w6d]
Pregnancy?
No
No
Amniotic Fluid AFP
[diagnostic test]
[<21w6d]
Yes
Yes
(Note: not gestational diabetes)
Previous amniocentesis or chorionic villus sampling
during this pregnancy?
Is this an IVF pregnancy?
No
Yes
amniocentesis or
CVS
No
Yes
Egg Donor Birth Date
_________________
(even if patient is donor):
Previous screen report during this pregnancy?
(yyyy/mm/dd)
No
Yes
for Open Spina Bifida
Egg Harvest Date
_________________
(if egg/embryo was frozen):
(yyyy/mm/dd)
for Down Syndrome
Ultrasound (U/S) Information
Sonographer or ordering provider to complete. Identify U/S operator code only if doing IPS or FTS.
cm
cm
Singleton/Twin A:
mm BPD:
mm
mm
CRL:
NT:
Crown-Rump Length
Bi-Parietal Diameter
Nuchal Translucency
U/S Date:
-
-
CRL between 41-84 mm or BPD<26mm
yyyy
mm
dd
cm
cm
Twin B:
dichorionic
mm BPD:
mm
mm
CRL:
NT:
monochorionic
Crown-Rump Length
Bi-Parietal Diameter
Nuchal Translucency
uncertain
CRL between 41-84 mm or BPD<26mm
U/S site:______________________________ U/S phone #: ______________
U/S Operator Code: _______________ Initials:
Ordering
Additional
Provider:
Report To:
Address:
Address:
Phone: (
)
FAX: (
)
Phone: (
)
FAX: (
)
Signature :
For Collection Centre Use Only
Send 2 mL of serum to the laboratory indicated above (serum separator tube preferred). Do not anticoagulate or freeze blood.
Centrifuge. Send primary tube to laboratory if there is a gel barrier, otherwise aliquot.
Specimen Date
℡
___________________
L L a a b b L L a a b b e e l l
Collection Centre
________________
Lab Label
__________________________
(yyyy/mm/dd)
address