Prenatal Screening Form
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PRENATAL SCREENING
FBR
FOUNDATION FOR BLOOD RESEARCH
Requisition for submitting
FBR
FBR
Mailing Address:
Shipping Address:
Tel: (207) 883-4131
FIRST or SECOND TRIMESTER SAMPLES
P.O. Box 190
8 Science Park Road
toll free: 1-800-639-8605
Website
Website
for Prenatal Screening
Scarborough, ME 04070-0190
Scarborough, ME 04074
FAX: (207) 883-1379
BEST RESULTS IF BLOOD DRAWN BETWEEN
o
o
o
PLEASE CHECK :
BILL SENDER
BILL PATIENT
BILL INSURANCE
________/_________/_________
AND
________/________/__________
If insurance information or patient address are not provided, charges will be submitted to Sender
PATIENT NAME: LAST, FIRST MIDDLE
SENDER: (Hospital or Laboratory ID)
FOR FBR USE ONLY
Clear Form
BILLING ADDRESS (STREET No. or P.O. BOX)
CITY
STATE
ZIP CODE
FOR PATIENT OR INSURANCE BILLING — COMPLETE THE INFORMATION BELOW
DATE OF BIRTH
SEX:
Primary Ins
Secondary Ins
M
F
SUBSCRIBER
SAMPLE DRAW DATE
INS. CO. NAME
ID CERT. NO.
REFERRING PROVIDER
GROUP NO.
STATE
PATIENT ID / ACCOUNT CODE
HOSP. LAB ORDER CODE
Information relative to these testing services may be requested from or released to third
parties for the purposes of clinical assessment or to process claims for payment of benefits.
CHECK TEST(S) REQUESTED
First Trimester (10w,3d - 13w,6d ga)
Second Trimester (15-21 wks ga)
o
o
INTEGRATED SCREEN Part 1
INTEGRATED SCREEN Part 2
(PAPP-A component)
(AFP, Estriol, hCG, Inhibin
st
st
Full Integrated
requires 1 trimester NT measurements
plus an ultrasound dated 1 trimester PAPP-A component)
st
Serum Integrated
needs only the 1 trimester sample
o
SEQUENTIAL SCREEN Part 2
(AFP, Estriol, hCG, Inhibin
st
plus an ultrasound dated 1 trimester PAPP-A component)
o
SEQUENTIAL SCREEN Part 1
(PAPP-A component)
requires nuchal translucency (NT) measurements
o
AFP PROFILE FOUR
(AFP, Estriol, hCG, Inhibin)
o
FIRST TRIMESTER SCREEN
(PAPP-A, hCG, Inhibin)
o
requires nuchal translucency (NT) measurements
AFP ONLY– for NTD screening only
o
Unless this box is checked, any remaining sample and clinical information may be used to develop future laboratory tests.
PART A
Dating information is required for interpretation of results
o
LMP date: _____ / _____ / _____
U/S date: ____ / ____ / ____
GA on U/S date: _____ wks, _____ days
Check box if by BPD.
Sonographer
Site where
U/S date: _____ / _____ / _____
NT: ______ mm
CRL: ______ mm
name: _________________________ U/S done_________________
o
o
o
If twin pregnancy:
twin B NT: ______ mm
twin B CRL: ______ mm
Chorionicity:
Mono
Di
Unknown
PART B
Patient background is required for proper risk assessment
o
o
o
o
Race/Ethnicity :
Caucasian
Black
Hispanic
Other
Height: _________
Weight (lbs.) : __________
Pregnancy History
: Vaginal bleeding this pregnancy?
Y
N
Insulin dependent diabetic
prior to this pregnancy?
Y
N
Cigarette smoker? If yes, how many per day? _______
Y
N
Number of fetuses this pregnancy
:
________
Has the patient already had...
Fetal demise this pregnancy
?
If yes, explain (comments)
Y
N
o
o
Amniocentesis?
or
CVS?
date _____/ _____/_____
If IVF pregnancy
,
age of donor at time of egg retrieval:
________
o
First trimester test for Down syndrome? date _____/ _____/_____
Previous pregnancy
diagnosed to have Down syndrome?
Y
N
COMMENTS
Family history:
Spina bifida, Anencephaly, or Hydrocephaly?
Y
N
If yes, describe:
Vers. 7/12
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