PleasePlease place place collection collection kit kit INTERNATIONAL barcode here. REQUISITION FORM barcode here. REQUISITION FORM 123456-2-X PLEASE COMPLETE ALL FIELDS. REQUISITION FORMS SUBMITTED WITH MISSING INFORMATION MAY CAUSE A DELAY IN TURNAROUND TIME OF THE TEST. PLEASE COMPLETE ALL FIELDS. REQUISITION FORMS SUBMITTED WITH MISSING INFORMATION MAY CAUSE A DELAY IN TURNAROUND TIME OF THE TEST. PATIENT INFORMATION ORDERING CLINICIAN INFORMATION PATIENT NAME (LAST, FIRST) NAME OF ORGANIZATION 1 PatIENT INFORmatION (Must be completed in English) 2 ORDERING CLINICIAN (Must be completed in English) DATE OF BIRTH (MM/DD/YYYY) Organization (Clinic, Hospital, or Lab): Patient Name (Last, First): ADDRESS TELEPHONE CITYPatient DOB (DD/MM/YYYY): STATE ZIP CODE ORDERINGLIMS-ID: CLINICIAN TELEPHONE EMAIL Patient Street Address: Telephone: I would like to receive emails about my test from Natera Y N City: Country: Ordering Clinician: PATIENT MALE OR FEMALE? M-V26.34 F-V26.31 PATIENT PREGNANT? Y-V22.1 N DATE OF SAMPLE COLLECTION (MM/DD/YY):_____________________________ Telephone: Email: PAYMENT PLEASEPatient CHECK male orONE: female: M F BILL INSURANCE BILL CLINIC BILL CLINIC/CA Prenatal SELF-PAY Patient pregnant? Program YPDC N INSURANCE COMPANY (Please enclose a photocopy (front and CLINICIAN INFORMED CONSENT MEMBERDate of ID sample collectionSUBSCRIBER (DD/MM/YYYY): NAME (if different than patient) back) or all relevant insurance cards) If you would like the results of this case to be sent to an additional FAX fax number other than what is indicated on your setup form, please IF SELF-PAY, CHECK CARD TYPE: VISA MASTER CARD AMEX DISCOVER provide the fax number. NAME ON CARD CREDIT CARD NUMBER STATEMENT OF INFORMED CONSENT I confirm that this patient has been informed about the details including the risks, benefits and limitations of the 3 genetic test(s) ordered on this form, and has given consent for the testing as may be required under applicable law. CVV EXPIRATIONPAYMEN T(MM/YYYY) PATIENT SIGNATURE Physician/Authorized Signature ______________________________________ Disposition or Retention of Samples Bill Clinic Self-Pay PATIENT ACKNOWLEDGEMENTLaboratory (Reseller) represents and confirms that the patient has given informed I confirmIf self thatpay, I have complete been informed the followingabout the details information: of the tests ordered for me by my provider including one or more of the following: Panoramaconsent prenatal in compliancescreen, Horizon genetic with carrierapplicable screen, or law Anora to products Natera’s of conception following test, includingsample their disposition (its) risks, benefits and limitations, and I voluntarily consent to testing. I understand I am financially responsible for services performed; including any copayments,or retention deductibles, policy: or other PATIENT amounts deeme UNDERSTANDSd ‘patient responsibility’ AND prior toCONSENTS test services being THAT: performed. (i) her/his I authorizeCheck Natera card or other type: provider to submit VISA claims to my MASTERCARD medical insurance on my behalf, AMEX if applicable, with DISCOVER all benefits of my plan made payablesample directly will to Natera be sentor other to provider. the UnitedNOTE: Patients States tested for pursuant performance to California’s Prenatalof the Screeningtest; (ii) Program Natera will not be billed for the ‘Panorama Prenatal Panel’ when 22q11.2 is opted out. may retain the patient’s leftover, de-identified samples to use for medical and Natera may keep my leftover de-identified samples for ongoing research and development. I and my heirs will not receive any payments, benefits, or rights to any resulting products or discoveries. If I do not want my de-identified sample used, I may send a requestName in writing on card: to Natera at Attn: Sample Retention, 201 Industrial Rd, Ste 410, San Carlos, CA 94070, or an email to [email protected] within 60 days advancement, after test results have research been issued & and development, my sample will be productdestroyed. NOTE:validation All samples and from quality patients residing in the state of New York will be destroyed within 60 days after the sample has been collected. assurance, independently or in collaboration with third-party partners, either in PatientCredit Signaturecard number:__________________________________________________________________________________________________________________or outside the United States; and (iii) patient and patient’s Date_____________________ heirs will not receive any payments, benefits, or rights to any resulting products or discoveries. If the patient does not want his or her de-identified sample used, the patient may send CCV: TEST ORDERING Expiration (DD/MM/YYYY): (SEE TEST DESCRIPTIONS SHEET FOR TEST EXPLANATIONS) a request in writing to the clinic or laboratory where the test was ordered within TM TM TM PANORAMA PRENATAL SCREEN HORIZON CARRIER60 days SCREEN after test results have beenANORA issued, andMISCARRIAGE such clinic or laboratory TEST will work Patient signature: PANORAMA PANEL OPTIONS: HORIZON PANEL OPTIONS:with Natera to destroy theANORA sample. OPTION: PANORAMA PRENATAL PANEL 10 mL 10 mL Number of conditions screened for ANORA MISCARRIAGE TEST 6 mL CODES FOR ALL PANELS: V77.6, V78.2, V77.7, V78.3, 783.9 Chromosomes 13, 18, 21, X and Y; Triploidy; 22q.11.2 deletion DATE OF PREGNANCY LOSS (MM/DD/YY): _________________ 4 HORIZONTM TEST ORDERING (SEE TEST DES4 (SMA,CRI PTCF, IONSFRAGILE S X,H EEDMD)T FOR TEST E10XPLA mL NATIONS) I DO NOT WANT 22Q.11.2 27 (PAN-ETHNIC STANDARD) GESTATIONAL AGE AT LOSS (WEEKS): ____________________ or PANORAMA EXTENDED PANEL 10 mL 10 mL 106 (COMPREHENSIVE JEWISH) THIS PREGNANCY WAS: PanoramaHORIZON Prenatal PANE PanelL O PTPLUSIONS 4 additional: microdeletions 137 (PAN-ETHNIC LARGE) Family history of2mL intellectual SINGLETON disabilities TWINS TRIPLETS OTHER 274 (PAN-ETHNIC EXTENDED) For any panel or CF I WANT FETAL SEX REPORTED IF MULTIPLES: IDENTICAL NON-IDENTICAL UNKNOWN Number of conditions screened for ADD TAY-SACHS ENZYME Familyor SMA history single optionsof other diseases of the musculoskeletal system and WAS AN EGG OR SURROGATE USED: Y N 4 (SMA, CF, Fragile X, DMD) (Available for Horizon 27, 106, 137,connective 274) tissue MATERNAL HEIGHT: __________ FEET _________ INCHES IF D&C, HOSPITAL OR SURGERY CENTER NAME: MATERNAL 27 (Pan-ethnic WEIGHT: Standard)_________ POUNDS SINGLE OPTIONS: Family history of carrier ______________________________________________________of genetic disease 10 mL or 10 mL GESTATIONAL 106 (Comprehensive AGE:__________ Jewish)_ WEEKS _______ DAYS If no panels are selected Family history of other specified conditions SAMPLE TYPE: FRESH PARAFFIN IS THIS A TWIN OR MULTIPLE GESTATION PREGNANCY? Y N CF-V77.6 SMA -V77.6, V78.2, V77.7, V78.3 137 (Pan-ethnic Large) TAY-SACHS ENZYME -V77.6, V78.2, Encounter V77.7, V78.3for genetic counselingPlease submit a parental blood sample. If egg donor Patient must be at least 9 weeks gestational age 274 (Pan-ethnic Extended) (Saliva is not available for Enzyme; requires an additional tube when was used, please submit sample from biological father. ETHNICITY: DUE DATE (MM/DD/YY):______________ ordered with a panel) Both parental samples are needed for paraffin testing. WASSample AN EGG requirement DONOR OR for SURROGATE Horizon Panel USED? Options: Y N Northern European (e.g. British, German, Irish) ETHNICITY: BLOOD SAMPLE COLLECTED IS 1THE 10mL MOTHER Lavender A KNOWN-top MICRODELETIONK2 EDTA blood CARRIER?tube Y N Southern European (e.g. Italian, Mediterranean, Greek) AFRICAN AMERICAN MEDITERRANEAN FROM (NAME): _____________________________________ WILL THE FATHER'S SAMPLE BE SUBMITTED WITH THIS CASE? E ASIAN SE ASIAN Ashkenazi Jewish BIOLOGICAL MOTHER BIOLOGICAL FATHER PLY EASEN IFSE YES,LECT NAME:____________________ ALL APPROPRIATE CL DOB:___________INICAL INDICATIONS CAUCASIAN: ASHKENAZI JEWISH East Asian (e.g. Chinese, KorGESTATIONALean, Japanese) CARRIER Father’s Screening sample formust other be submittedmetabolic indisorders same kit SEPHARDIC JEWISH FRENCH CANADIAN South Asian* (e.g. Indian, Pakistani) Nonprocreative screening for genetic disease carrier status HISPANIC/LATIN AMERICAN PLEASE SELECT ALL APPROPRIATE CLINICAL PLEASE CHECK ALL APPROPRIATE OTHER: _______________________________________ South-East Asian (e.g. Filipino,INDICATIONS: Vietnamese) Other screening for genetic and chromosomal anomalies CLINICAL INDICATIONS: IS THE PATIENT CURRENTLY USING African or African American RECURRENT LOSS, NOT PREGNANT- 629.81 Screening for other disorder ADVANCED MATERNAL AGE, 1ST PREGNANCY-659.53 / V23.81 HORMONAL MEDICATIONS? Hispanic LOSS WITH RETENTION AFTER 22 WKS - 656.40 ADVANCED Female for MATERNAL testing for AGE,genetic NOT disease 1ST PREGNANCY-659.63 carrier status for procreative / management Y-V22.1 N UNSPECIFIED ABORTION WITHOUT MENTION OF Middle Eastern* V23.82 Male for testing for genetic disease carrier status for procreative managementPLEASE SELECT ALL APPROPRIATE CLINICAL COMPLICATION - 637.90 Other/mixed Caucasian* ABNORMAL/POSITIVE Pregnant state, incidental SERUM SCREENING-796.5 INDICATIONS: LOSS WITH RETENTION PRIOR TO 22 WKS - 632 ANEUPLOIDY IN MOTHER, FETAL ANEUPLOIDY-655.13 FAMILY HISTORY (GENETIC DISEASE)Is the patient -V18.9 currently using hormonal medications? Supervision of normal 1st pregnancy, 1st trimester BLIGHTED OVUM [OTHER ABNORMAL POC] - 631.8 SUPERVISION OF HIGH-RISK