Preconception / Prenatal Cystic Fibrosis (Cf) Screening Form

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FBR
Mailing Address:
Shipping Address:
Tel: (207) 883-4131
FOR LAB USE ONLY
FOUNDATION FOR BLOOD RESEARCH
P.O. Box 190
8 Science Park Road
ME Only: 1-800-639-8605
Clear Form
Scarborough, ME 04070-0190
Scarborough, ME 04074
FAX: (207) 885-0807
FBR
FBR
Website
Website
PRECONCEPTION / PRENATAL CYSTIC FIBROSIS (CF) SCREENING REQUISITION
o
o
o
PLEASE CHECK :
BILL SENDER
BILL PATIENT
BILL INSURANCE
If insurance information or patient address are not provided, charges will be submitted to Sender
PATIENT NAME:
LAST, FIRST
MIDDLE
PARTNER NAME:
LAST, FIRST
MIDDLE
(female)
(male)
MAILING ADDRESS (STREET No. or P.O. BOX)
MAILING ADDRESS (STREET No. or P.O. BOX)
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
DATE OF BIRTH
PATIENT ID ACCOUNT CODE
DATE OF BIRTH
PATIENT ID ACCOUNT CODE
DATE SAMPLE COLLECTED
SAMPLE TYPE (circle one)
DATE SAMPLE COLLECTED
SAMPLE TYPE (circle one)
Cheek SWAB
or
BLOOD
Cheek SWAB
or
BLOOD
ORDERING PHYSICIAN
PRACTICE NAME
ORDERING PHYSICIAN
PRACTICE NAME
PREGNANT? (circle one)
DIAGNOSIS / ICD-9 CODES
DIAGNOSIS / ICD-9 CODES
YES, _______ wks
or
NO
PATIENT’S INSURANCE
PARTNER’S INSURANCE
PRIMARY INSURANCE CO.
PRIMARY INSURANCE CO.
ID or CERTIFICATE No.
ID or CERTIFICATE No.
SECONDARDY INSURANCE CO.
SECONDARY INSURANCE CO.
ID or CERTIFICATE No.
ID or CERTIFICATE No.
SELECT METHOD FOR TESTING (check one)
{
Send both patient and partner samples together for optimum screening results.
CF COUPLE SCREENING
His sample will be tested only if necessary to determine a screening outcome.
{
Send only her sample at this time, but include background and history for both.
CF SEQUENTIAL TEST
His sample will be requested if she is identified as a CF carrier.
Please answer all questions in this section even if only one sample is being sent
PATIENT’s Racial / Ethnic Background:
PARTNER’s Racial / Ethnic Background:
[ ] Ashkenazi Jewish
[ ] African American
[ ] Ashkenazi Jewish
[ ] African American
[ ] White (non-Hispanic)
[ ] Asian American
[ ] White (non-Hispanic)
[ ] Asian American
[ ] Hispanic American
[ ] Other _______________
[ ] Hispanic American
[ ] Other ______________
CF Family History: Does the patient know if she
CF Family History: Does the partner know if he
[ ] NO,
[ ] NO,
or don’t know
or don’t know
or one of her
blood
relatives has Cystic Fibrosis or
or one of his
blood
relatives has Cystic Fibrosis
[ ]
YES
[ ]
YES
, please check
, please check
appropriate boxes below.
appropriate boxes below.
is known to be a CF carrier?
or is known to be a CF carrier?
has
carrier
has
carrier
has
carrier
has
carrier
CF
only
CF
only
CF
only
CF
only
Self
[ ]
[ ]
Grandparent
[ ]
[ ]
Self
[ ]
[ ]
Grandparent
[ ]
[ ]
Previous Child [ ]
[ ]
Aunt/Uncle
[ ]
[ ]
Previous Child [ ]
[ ]
Aunt/Uncle
[ ]
[ ]
Mother/Father
[ ]
[ ]
Cousin
[ ]
[ ]
Mother/Father
[ ]
[ ]
Cousin
[ ]
[ ]
Sister/Brother
[ ]
[ ]
More distant
Sister/Brother
[ ]
[ ]
More distant
Niece/Nephew [ ]
[ ]
relative
[ ]
[ ]
Niece/Nephew [ ]
[ ]
relative
[ ]
[ ]
If known, what mutations were identified? __________________
If known, what mutations were identified? __________________
Before you agree to this testing, you must read the information on the next page.
PATIENT
PARTNER
I have read about CF screening and want to have this testing done.
I have read about CF screening and want to have this testing done.
Signature________________________ Date ___________
Signature________________________ Date ___________
Note: Unless this box is checked, any remaining sample may be used
Note: Unless this box is checked, any remaining sample may be used
[ ]
anonymously to develop future laboratory testing.
[ ]
anonymously to develop future laboratory testing.
RETURN THIS PAGE TO THE FBR ALONG WITH THE SAMPLE(S) COLLECTED
Vers. 3/13

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