AFP Maternal Screen Information Request Form PLEASE SUPPLY THE INFORMATION CHECKED BELOW TO COMPLETE THIS PATIENT'S REPORT 0 Maternal Date of Birth: ___/_ 1 Date of Sample Collection: —_/_ J o Maternal Weight: - Les. co Number of Fetus: (CIRCLE) 1 2 3 If more than 3, © Maternal Race: __African American, Asian, Caucasian, Hispanic, Other 1 History of Down Syndrome? (CIRCLE) YES NO 1 Insulin Dependent Diabetic? (CIRCLE) YES NO 5 FIRST _ OR SECOND __ SPECIMEN. 1 Family History of Neural Tube Defect? (CIRCLE) YES NO 0 Estimated Date of Delivery __/___/ EDD determined by (CIRCLE ONE): Ultrasound __, Physical _, LMP __ ‘THIS INFORMATION 1S REQUIRED FOR tat TRIMESTER SCREENING AND PART 1 INTEGRATED / SEQUENTIAL SCREEN! 0 Ultrasound Date: __/__/__.__ 5 Ultrasonographer's First & Last Name: © Nuchal Translucency Measurement Credentialing Agency (required, check one box) 5 NTQR Ultrasonographer's ID#: ocation Ii: emer Reading Physician ID#: __ o FMF - Ultrasonographer's ID# 5 Other (List): Init 7 Crown Rump Length (CRL) __ am co Nuchal Translucency (NT) mm DEDDfromcRL J / c If twin gestation, are the twins = Dichorionic a Monochorionic Twin B CRL mm = Twin BNT __mm 1 Pregnancy is from a donor egg: a Yes oc No 1c Age or Date of Birth (DOB) of Donor: c Other Relevant Clinical Information: LAB FORO,® GENESIS WS Clinical Laboratory Cystic Fibrosis, DNA Probe Analysis Patient Profile To insure accurate evaluation of this patient's specimen, please complete this sheet and send with your specimen. “The information requested below is needed to provide accurate testing services and interpretations. Patient, Date of birth. Sex: (JM [JF Requesting Physician: Telephone Number: __ Fax Number: Indication for Test: (1) Confirmation of Diagnosis, Affected Individual OO Carrier Screening Status of Partner 0 _Untested (2 Being tested concurrently Negative by mutation analysis (el) Carmen cheese mutation (1 Carrier testing for Persons with a Positive Family History (attach Pedigree) Abnormal fetal ultrasound, echogenic bowel Oo LJ Congenital Absence of Vas Deferens Ethnic Origin of Patient (Caucasian =~ [] Ashkenazi Jewish CD Hispanic « (1 African American = [] Asian (other Other Important Clinical Information: Patient's Signature: Date: Rerven Fay TO: 703-F02-72¢/PPR-LS- CMe BSIE( PRUNE EINE DAS CE atyaurun wine bee fem Quest @ Diagnostics INSTRUCTIONS FOR SUBMITTING AMNIOTIC FLUID FOR CHROMOSOME ANALYSIS Itis essential that every effort be made to insure the sterility of the amniotic fluid specimen since biological contamination may result in culture failure, 1 Perform amniocentesis on Monday through Thursday, if possible. Call the eytogenetics laboratory at (703) 802-7156 to notify that laboratory that a specimen is being sent, Call the Quest courier denartment for specimen pick-up at (703) 802-7272 (Local) or (800) 336-3718 and press 2, if the specimen is not ineluded with a routine courier run, Complete the enclosed gencties requisition (Test code 14590 or 14591, formerly test code 1370) and consent and clinical history form. Patient must sign a consent form. Obtain approximately 20~25 mL of amniotic fluid, and aseptically transfer half ofthe specimen into exch of the tubes in the kit. Include ~SmL more fluid if FISH testing is to be performed, Check to be sure the cap is properly aligned to prevent Icakage of specimen. Secure cap with parafilm, Complete the specimen label attached to the tube. Maintain amniotic fluid at room temperature. Do not subject the specimen to extremes in temperature. Do not freeze. If alpha-fetoprotein (AFP) (Test code 7993) analysis is to be performed, indicate this ((est code 14591) on the cytogenetics consent form and complete the enclosed Genetics Requisition Form for testing. Do not submit separate specimens for these tests. Cytogenctics laboratory personne] will separate the specimen for these tests, Acetylcholinesterase is automatically performed for AFP values greater than 2.0 MoM A cytogenctic analysis of amniotic fluid takes ten days to two weeks to complete. If a culture failure is an ipated, the requesting physician ot laboratory will be notified by telephone.COME UIICO PRUNEENEDLS ChANdure Crus ens roy wre 7 Quest @ Diagnostics AMNIOTIC FLUID SPECIMENS SUBMITTED FOR CYTOGENETIC ANALYSIS: ‘The following informetion and completed Consent Form are required to process the specimen, PATIENT NAME AGE, AGE OF FATHER, WEEKS GESTATION (US)____(UMP)___DATE & TIME OF AMNIOCENTESIS PHYSICIAN, PHYSICAN PHONE (__) INDICATION FOR PRENATAL DIAGNOSIS _-Advanced maternal age Indicated by maternal serum AFP Indicated by triple screen results Previously affected offspring. Specify, ‘Translocation carrier or abnormal parental karyotype. Specify Other, Specify History of recent exposure of parents or fetus to radiation, drugs, or infectious agents. Alpha-fetoprotein determination requested: YES____NO. Acetvicholinesterase is performed for AFP > 2.0 Mo 1, CONSENT TO USE AMNIOTIC ELUID FOR DIAGNOSIS 1___ request and authorize Quest Dingnostios to perform prenatal determinations of the chromosome constitution of my fetus for the purpose of detecting certain birth defects, The procedure has been explained to me and I understand that: 1. There are a variety of birth defects and causes of mental retardation that cannot be diagnosed by the above named study, 2. There is @ possibility that growing fetal cells may not be successful and that no results will be obtained. 3. Test results cannot be guaranteed to be 100% accurate and there is a possibility that che chromosome study might not accurately reflect the status of my fetus. For example, cells from the mother may on rare occasions be in the sample provided. Repeat amniocentesis may be required. 5. In the case of a presently undiagnosed multiple pregnancy (e.g, twins), results pertain to only one fetus 6. tf Quest finds it necessary, my amniotic fluid specimen may be sent to another qualified laboratory for diagnosis and/or paralle testing 7. After completion of the diagnostic tests, some of the sample may be saved for research purposes. L author ihe eclase of pertinent medical information regarding me, my unborn child, ineluding information relating to my child after it is bom, needed by Quest for the performance of the above test or confitmation of their result, Patient Signature ‘Witness Signature Date