Get Nj Mercy Diagnostics Patient History Form For Non-invasive Prenatal Testing (nipt) 2014-2025

Completing the NJ Mercy Diagnostics Patient History Form for Non-Invasive Prenatal Testing is a crucial step for individuals seeking this form of prenatal care. This guide provides clear, step-by-step instructions to help users fill out the form accurately and efficiently.

Follow the steps to complete the form effectively.

1. Select the ‘Get Form’ button to obtain the NJ Mercy Diagnostics Patient History Form and open it for completion.
2. Provide your full patient name in the designated field.
3. Enter your date of birth in the format specified.
4. Fill in your physician or genetic counselor’s name along with their contact phone number, fax, and pager or cell number.
5. Indicate the draw date and gestational age at the time of the blood sample draw.
6. Select the fetal gender as indicated by ultrasound by checking the appropriate box: Male, Female, or Ambiguous.
7. Input your current weight in pounds or kilograms in the corresponding fields.
8. Select your race by checking a box: Caucasian, Black, Hispanic, Asian, or Other.
9. Answer whether you are carrying more than one fetus or if there is a known twin demise by checking Yes, No, or Unknown.
10. Indicate if you are the genetic mother of the fetus by checking Yes or No, noting that NIPT is not appropriate if you are not the genetic mother.
11. Check all indications for testing that apply to your situation, which may include advanced maternal age or family history.
12. If applicable, provide the father's name and date of birth.
13. Indicate whether you want to know the sex of the fetus by checking Yes or No.
14. Circle the specific test you intend to order from the options provided.
15. Read the informed consent section carefully before signing and dating the patient consent statement.
16. Have your physician/genetic counselor complete their section by printing their name, signing, and providing their phone number.
17. Once all sections are completed, save your changes, and proceed to download, print, or share the form as needed.

Complete your NJ Mercy Diagnostics Patient History Form for Non-Invasive Prenatal Testing online today.