Prenatal Testing 2nd Trimester Form
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1
2FBR
Second Trimester
FOUNDATION FOR BLOOD RESEARCH
FBR
FBR
PRENATAL TESTING REQUISITION
Website
Website
Mailing Address:
Shipping Address:
Tel: (207) 883-4131
P.O. Box 190
8 Science Park Road
toll free: 1-800-639-8605
for serum or amnio
Scarborough, ME 4070-0190
Scarborough, ME 04074
FAX: (207) 883-1379
PLEASE HAVE BLOOD DRAWN BETWEEN
o
o
o
PLEASE CHECK :
BILL SENDER
BILL PATIENT
BILL INSURANCE
If insurance information or patient address are not provided, charges will be subitted to Sender
________/_________/_________ AND
________/________/__________
SENDER: (Hospital or Laboratory ID)
FOR FBR USE
PATIENT NAME: LAST, FIRST MIDDLE
BILLING ADDRESS (STREET No. or P.O. BOX)
STATE
CITY
ZIPCODE
FOR PATIENT OR INSURANCE BILLING — COMPLETE THE INFORMATION BELOW
DATE OF BIRTH
SEX:
F
Primary Ins
Secondary Ins
SUBSCRIBER
SAMPLE TYPE:
SAMPLE DRAW DATE
INS. CO. NAME
REFERRING PROVIDER
REFERRING PROVIDER SIGNATURE
ID CERT. NO
GROUP NO
PATIENT ID ACCOUNT CODE
HOSP. LAB ORDER CODE
STATE
DIAGNOSIS
(text or ICD9 codes)
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
AFP SERUM STUDIES (complete part A)
AMNIOTIC FLUID STUDIES (complete part B)
AMNIOTIC FLUID AFP
Plus reflexive AChE and Contamination studies if indicated
AFP PROFILE FOUR
(
AFP, Estriol, hCG, Inhibin
)
o
Omit all reflexive testing and associated charges
ACETYLCHOLINESTERASE priority panel (AChE)
Includes AChE, AFAFP; plus add’l reflexive studies as indicated
o
AFP ONLY – for Neural Tube Defect screening only
Omit add’l reflexive testing and associated charges
(after CVS/amnio, elevated AFP or first trimester test)
FETAL BLOOD CONTAMINATION (FBC)
BOVINE SERUM (BSA) CONTAMINATION
o
Unless this box is checked, any remaining sample and clinical information may be used to develop future laboratory tests.
Is this test a repeat?
Y
N
PART A
LMP date: _____ / _____/ _____
U/S date
: ____ / ____ / ____
GA on U/S date
: ______ wks, ____ days
Check box if by BPD
Race:
Caucasian
Black
Other
Height: _________
Current
weight
(lbs.) : _________
Insulin dependent diabetic prior to this pregnancy?
Pregnancy History: Vaginal bleeding this pregnancy?
Y
N
Y
N
Multiple pregnancy?
If yes, number of fetuses: ______
Y
N
Cigarette smoker? If yes, how many per day? ______
Y
N
Fetal demise this pregnancy?
If yes, explain (comment)
Y
N
Has the patient had...
IVF this pregnancy?
If donor egg, age of donor: ______
Y
N
Amniocentesis? or
CVS?
date _____/ _____/_____
Previous pregnancy
Down syndrome?
diagnosed to have
Y
N
Family history
: Spina bifida, Anencephaly, or Hydrocephaly ?
Y
N
First trimester test for Down syndrome?
date _____/ _____/_____
If yes, describe:
PART B
REASON FOR AMNIOCENTESIS
COMMENTS
o Elevated serum AFP
o
Abnormal U/S (explain)
o
o
o
Screen positive for DS
History of NTD
History of chromosome disorders
o
o
Advanced maternal age
Other (specify)
LMP date:
If
U/S,
_______ wks GA on date : ____ / ____ / ____
_____ / _____/ _____
o
o
This specimen is:
supernatant
whole fluid
Is it blood stained ?
Y
N
Vers 1/11
.
FBR COPY
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