REQUEST FORM GENETIC ANALYSIS NON-INVASIVE PRENATAL TEST(NIPT) version2/20141125 CENTRE FOR MEDICAL GENETICS UZ Brussel Label health insurance Laarbeeklaan 101 - 1090 Brussel secretary laboratory: tel. +32 (0)2 477 64 79 - fax. +32 (0)2 477 68 59 secretary consultation: tel +32 (0)2 477 60 71 - fax +32 (0)2 477 68 60 www.brusselsgenetics.be ISO15189 accreditation (BELAC) A separate form has to be filled completely in CAPITALS per patient. A genetic test will only be started after receipt of a fully completed and signed request form. Identification referring physician Identification mother Surname patient: Surname physician: Name patient: Date of birth: Name physician: Sex (M/F): Address: Referring service: Address: Email: Health insurance: Telephone: Membership Nr: RIZIV/INAMI number: UZ Brussel file Nr: Signature: Family Nr: Ethnic origin: Date request: Your reference: Data pregnancy Copy result to: Length of the mother: Address: Weight before pregnancy: Actual # of weeks pregnant according to ultrasound: Language of choice for genetic report Attention! NIPT is less reliable before 11 weeks of pregancy History Date ultrasound: Number of fetuses: Chorionicity: DC/DA Prior screening test performed: Result risk calculation: T21: 1/ T18: 1/ MC/DA MC/MA yes no 1st trimester: 2nd trimester: biochemistry biochemistry Integrated 1st + 2nd trimester Pregnancies: GPA: Miscarriage TOP Extra uterine T13: 1/ Molar Type prior screening test: None English ultrasound ultrasound History of genetic disorder: In previous pregnancy Specify: In mother Other In family Specify: Specify: Indication According to guidelines (blood sampling: 1x10mL in Streck tube) 1St 1St 1St 1St Combination test with increased risk for trisomy (>1/300) Maternal age (> of = 35 years): years Abnormal ultrasound suggestive for trisomy 21 1St Abnormal ultrasound suggestive for other numerical anomalies 1St History of aneuploidy or other chromosomal anomalies Other (blood sampling : 1x10mL in Streck tube) 1St 1St 1St 1St Personal request of patient Pregnancy after Other Specify: IVF ICSI PGD Specify: Sample information 1St 1x 10 mL blood in Streck tube (according guidelines/other) Collection date: Request date: Collection time: Request time: Attention! minimally 8mL/tube required Storage & transport: at room temperature for 1 day / at cooling temperature up to 4°C if >1 day - freezing should be absolutely avoided Dutch CONSENT FORM GENETIC ANALYSIS NON-INVASIVE PRENATAL TEST(NIPT) version2/20141125 CENTRE FOR MEDICAL GENETICS UZ Brussel Label Health Insurance Laarbeeklaan 101 - 1090 Brussel secretary laboratory: tel. +32 (0)2 477 64 79 - fax. +32 (0)2 477 68 59 secretary consultation: tel +32 (0)2 477 60 71 - fax +32 (0)2 477 68 60 www.brusselsgenetics.be ISO15189 accreditation (BELAC) INFORMED CONSENT OF PREGNANT WOMAN 1. I have been informed about the possibilities and limitations of this test, as described in the information leaflet. I have had the opportunity to request additional information from my physician. 2. I understand that this test is intended for the detection of trisomy 21, 18 and 13, from 11 weeks of pregnancy onwards. Other, more appropriate tests may be offered when there is an increased risk of certain genetic disorders. 3. In the case of a normal test result, the probability that the fetus still has trisomy 21, 18 or 13 is very small, but cannot be completely excluded. An abnormal test result should be confrimed by an invasive prenatal test (amniocentesis) . 4. The result will usually be available 2 calendar weeks after receipt of the blood sample. 5. In approximately 5% of the cases, results cannot be obtained. In this case, a new blood sample can be drawn without any extra costs. 6. I understand that the costs of this test are € 460 (+ possibly indexation). There is currently no reimbursement by the Belgian national health insurance (RIZIV/INAMI), so the costs of this test are entirely charged to the patient. The laboratory that performs the test will send me the invoice directly. 7. In rare cases, NIPT can detect chromosome abnormalities other than trisomy 21, 18 or 13. In this case, the Centre for Medical Genetics UZ Brussel will contact me or my gynecologist so that further monitoring of the pregnancy can be modfied according to the findings. I UNDERSTAND THE ABOVE INFORMATION AND I AGREE THAT NIPT WILL BE PERFORMED FOR THE DETECTION OF FETAL TRISOMY 21, 18 AND 13. Mother Physician Name: Name: Signature: Signature: Date: Date: Surname patient: Name patient: Date of birth: Address: Sex (M/F): Health insurance: Membership Nr: UZ Brussel file Nr: Print Form