Order NIPTIFY

Sample ID (code on blood tube, 6 digits)

Clinic order code

Clinician's name

Clinician's phone number

Clinician's e-mail

Do we report the sex of the fetus?

Yes

Do we report incidental findings?

Yes

Single pregnancy?

Yes

Twin pregnancy?

Monochorionic (one placenta)

Dichorionic (two placentas)

First and surname of the patient

Patient's date of birth

Gestational age (weeks)

Date of blood sampling

Notes

By ordering, I confirm that I am ordering the NIPTIFY Focus Plus test at the patient's request. The test evaluates the risks of fetal trisomy of 13, 18, and 21 chromosomes, DiGeorge (22q11) microdeletion syndrome, monosomy X (45,X), and determines fetal chromosomal sex. I confirm that the patient has been informed about the possible results, risks, and limitations of the NIPTIFY Focus Plus test and has signed the consent form. I confirm that here presented data is correct.

NIPT test requisition form