Follow the steps to complete the requisition form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the clinic name, provider name, address, and phone number at the top of the form.
3. Enter the patient's legal name, including the last name, first name, and middle initial in the required field.
4. Input the patient's date of birth in the designated area.
5. Provide the last four digits of the patient's Social Security number in the specific field.
6. Select the patient's sex by marking either 'Male' or 'Female'.
7. Enter the collection date in the provided space.
8. Complete the patient's home address in the required field.
9. Fill out the DX code section with the appropriate medical codes.
10. Indicate the mother's ethnicity and weight, ensuring to provide accurate details.
11. Provide the estimated date of delivery and specify how it was determined.
12. Indicate the number of fetuses for the current pregnancy and specify the chorion if applicable.
13. Answer additional questions related to the pregnancy history, including any repeat tests and conditions.
14. For second trimester screens, provide additional required information about previous pregnancies and family medical history.
15. For first trimester screens, fill in ultrasound date, sonographer name, certification number, and nuchal translucency measurements.
16. Ensure to sign and date the authorization section at the bottom of the form.
17. Review all entered information to ensure accuracy before finalizing.
18. Once completed, save changes, and download, print, or share the form as needed.

Complete your form online today for efficient prenatal screening.