Non-Invasive Prenatal Test Request Form
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1Laboratory number
LABORATORY COPY
Clinipath Pathology
| Request Form
Non-Invasive Prenatal Test
FOR THE DOCTOR
Requesting Doctor
This test should be requested by the doctor responsible for managing a
Name
woman’s decision-making regarding Non-Invasive Prenatal Testing.
Address
Patient details
First name
Surname
Phone
Provider No
Female – Pregnant
Date of birth
/
/
Gender
I confirm that this patient has been counselled about the purpose, scope and
Address
limitations of the test and has given consent.
CLINICIAN SIGNATURE
Signature
Date
Phone (mobile)
Copy reports to
Name
Test/s requested
Address
SINGLETON
Harmony™ Prenatal Test
Monosomy X
FOR THE PATIENT – Patient consent
T21, T18, T13
Fetal gender
Sex chromosomes
I consent to the Harmony Prenatal Test being performed and confirm that I
aneuploidy panel
have been informed about the purpose, scope, and limitations of the test by my
doctor, patient literature, and/or the Sonic Genetics website. I understand that
the test is a screen for selected abnormalities of chromosomes 21, 18, and 13;
TWIN
that the test can also screen for less serious selected abnormalities of the sex
chromosomes, and identify fetal gender; that the result should be reviewed by my
Harmony™ Prenatal Test
Fetal gender
(detects presence of
doctor in the light of other findings; that a ‘high risk’ result should be confirmed by
one or two male twins)
T21, T18, T13
fetal karyotype; that a second collection may be required; and that 1-2% of tests
do not yield a result due to biological factors (with prepaid tests for chromosomes
21, 18, and 13 being refunded). I have had the opportunity to ask questions and
Is this a
RECOLLECTION?
Previous Lab ID
understand that I can request further information or genetic counselling.
I consent to my identified result being used with Government birth records
solely to audit the Harmony test, and understand that I would not be identified in
reports of such audits. [delete this sentence if you do NOT consent to releasing
Clinical Information
REQUIRED
your result for audit purposes].
ALL fields must be completed for testing to proceed.
PATIENT SIGNATURE
Signature
Date
Note If any of the clinical information changes, the lab must be notified as the
Collection Appointment and Payment
data captured below is included in the test algorithm.
To finalise the order of your Harmony test, please visit
com.au/payment to complete your booking and payment. You will then receive
GESTATIONAL AGE
an email and SMS with confirmation. Please make sure to bring this form and
booking confirmation with you on the day. Medicare benefits do not apply.
Either
Weeks
Days
as at
/
/
(date)
or
LMP
EDC
IVF
/
/
(date)
FOR THE COLLECTOR
CONCEPTION DETAILS
I certify I established the identity of the patient named on this request, collected
Natural
IVF (Patient egg) | Maternal age at egg retrieval
yrs
and immediately labelled the accompanying specimen(s) with the patient’s name,
IVF (Donor egg) | Maternal age at egg retrieval
yrs
DOB and date/time of collection.
Collector’s Name:
MATERNAL INFORMATION
Maternal weight (kg)
Maternal height (cm)
COLLECTOR SIGNATURE
Signature
Date
2 X NIPT tube
PAY CAT
Staff ID/Location code
Collection type (stamp)
SGU
Date collected
Harmony™ Prenatal Test is not validated for 3 or more fetuses, or in the presence of a
/
/
demised fetus. The Harmony™ Prenatal Test examines for certain aneuploidies in viable singleton
and twin pregnancies by natural or IVF conception after 10 weeks gestation. Specific exclusions are
Time collected
detailed at com.au. Please note that the requested clinical information is essential
:
for test accuracy.
This request form is issued by Sonic Healthcare Genetics Pty Ltd • ABN 98 100 145 748
TELEPHONE Sonic Genetics 1800 010 447 • EMAIL .au • WEB com.au
Sonic Healthcare Genetics Pty Ltd ABN 98 100 145 748, subsidiary of Sonic Healthcare Limited APA ABN 24 004 196 909
ISSUE MAR 2016
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