Patients name (name, feat name) ations date of birth harmony PRENATAL TEST x © cenata ‘ FROCUINICA Non-invasive screening test of trisomies 21, 18, 13, and X/Y-chromosomal aneuploidy Information about pregnancy atthe time of blood collection Gestational age woo dys act LMF: | 1 shobion pega 1 binpomney iin: 10) Please place the provided barcode label here To slegeoe 2 ansagoe Desires type of Harmony Test esc 2,181, thou XY analysis eon 2,181 inating X/Y analyse ony singleton pregnance 1 éeterinatin feta cox dees ‘nth natal eieaten The pent ras infomed aout he purpores Srdumestons othe harmony Tet ezcingtomy specie” Senet anaes. Wiiten permission forthe performance ofthe Harmony Test according to national legislation With my agnatue on the orm ave my consent have the Hameny® Tet parermes fom my taed samp conf tat nave cece counseling ae explanations tom my Tespontbephysclonn accordance wih sal ego, have hae te opportu te ak Questions and dics te test wh ry phyisan osomecne ny detr has dengated, stat fomee abate supeses spd imttion fhe Harman Tes am aware that may shan potessioal gene cousin fdsted bear sghng hie consent Tore infrmed tot he Harmeny Tete seni tek se at ntened 3 4nd or ght Cina shud ron hgh scary oft tery deo, bk nt Liber fetuses wl be dente by the Harnort@ Tes | am ane ta may revoke my consent tay tne nwrten frm tomy cco’ In aden nthe evento revocation | 37 agate pay fr the Serves encred sofa hereby ape tat he Haron Penal est processed By Meek Ser, Member of MEDIREX GROUP aan T/C, {20 rans, slovak cpu EUROPE Meier Sr sabes Scesod by Race aghosic ft he prtrance tte Havmony® Pent Teat. ena viating the rere th raison fhe rept othe psc esr te German aw Iwao ha Rave the gh rt be ret bad th se rer an x information concerning the Harmony Test he Harmony Tests a laboratery-bases screening test thal intended tea inthe ris determination of etal tisomy 21 ‘esomy 18, and trisomy 13 in women af a least 10 weeks af gestation ‘The Harmony Testis screening test anc nat intended or validated fr ciagnoss, Clnicl Studies demonstrate a high accuracy fo fetal tsomy detection, but natal semi fetuses wll be detected, Some fetuses witha trisomy may have “LOW RISK" results, Some eupeid (nt trim) fetuses may have “HIGH RISK’ ‘results Reels should be consicerd in the context of ther clinical tera, leis recommended that cesults ate communicated ina setting that ensures appropiate counseling, ‘The Hacmony Test may not be part af statutory heath cave an might have tebe paid by the patient. Ere ge E-malnfedcenata de Requesting physician x