Place Patient Stamp Here
Vanderbilt Diagnostic Laboratory
4605 TVC. Nashville, TN 37232
MR #:
Request for Prenatal Screening
Name:
Birthdate:
Date Collected
Month
Day
Time
Year
a.m.
Visit / Billing #:
p.m.
Sample No:
Tech Verification No:
D&H Account:_____________________________
Clinical Trial Patient: [__] Yes [__] No
Phlebotomist
Z00.6
Clinical Trial Patient, SOC Billed to Insurance
Z75.5
Clinical Trial Patient, Research Billed to D&H Account
Clinical Trial Diagnosis Codes:
Clinic Location Code:_________
ICD-10: (to be applied to all testing below unless otherwise specified) 1) __ __ __ . __ __ __ __ 2) __ __ __ . __ __ __ __
Requesting Physician:
Requesting Physician's Billing #:
REQUEST FOR PRENATAL SCREENING FOR NTD +/- DOWN SYNDROME
1) [__] Initial Specimen
[__] Recalculate based on new clinical information below.
[__] Repeat Specimen (Indicated only if previous MS AFP borderline or previous specimen for QUAD/MS AFP drawn too early)
2) [__] QUAD maternal serum screen for AFP, HCG, UE3, Inhibin A (PNQ)
[__]
MATERNAL SERUM AFP (MAF) This screening option only provides NTD risk assessment; therefore it should only be
ordered if CVS or first trimester screening (for chromosome abnormalities) was previously done in this pregnancy.
[__] AMNIOTIC FLUID AFP (AAF) with reflex testing for acetylcholinesterase if AFP elevated
3) [__] PT DOB: _______________ WEIGHT: ________ ETHNICITY: [__] WHITE [__] BLACK [__] HISPANIC [__] OTHER
4) Estimated gestational age at time of specimen collection: ______ Weeks ______Days,
Based on [__] LMP of _______ or [__] Ultrasound on Date _____________________ with EDD of _____________
5) Pregestational insulin dependent diabetes? [__] NO [__] YES
(Mark YES if she was in poor control in the first trimester [HgA1c>7.0] regardless of insulin use)
6)
[__] SINGLETON
7) IVF Pregnancy?
[__] TWIN
[__] OTHER MULTIPLE: _______________
[__] NO
[__] YES, age of egg donor _______
8) Previous pregnancy with neural tube defect? [__] NO [__] YES (If Yes, genetic counseling is indicted)
9) Previous pregnancy with Down syndrome? [__] NO
[__] YES (If Yes, genetic counseling is indicted)
REQUEST FOR FETAL LUNG MATURITY TEST (AMNIOTIC FLUID)
[__]
Lamellar Body Count (LBC)
[__] L/S RATIO (Please note this is a send out lab.)
Estimated gestational age at time of specimen collection: _____ Weeks _____ Days by EDD of ________ BY [__] LMP [__] Ultrasound
DATE OF LMP: _______________ DATE OF ULTRASOUND: _______________
REQUEST FOR DELTA OD 450 ANALYSIS IN AMNIOTIC FLUID
[__] DELTA OD 450 (PLEASE NOTE THIS IS A SEND OUT TEST)
Estimated gestational age at time of specimen collection: _____ Weeks _____ Days by EDD of ________ BY [__] LMP [__] Ultrasound
DATE OF LMP: _______________ DATE OF ULTRASOUND: _______________
CLINICAL INFORMATION SHOULD BE COMPLETED BY REQUESTING PHYSICIAN
Ordering Physician's Printed Name:__________________________ Signature:________________________________Date:_______________Time: _____ a.m. _____ p.m.
Lab Use Only
Lab # ________________________________
Date and Time Specimen Received:
_______/_______/_______
[__] a.m.
[__] p.m.
MC 0120
11/5/2015