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Get ARUP Laboratories Patient History Form for Non-Invasive Prenatal Testing (NIPT) 2016

Ate of Birth Ordering Provider Physician Phone Physician FAX Physician Pager/Cell: Genetic Counselor Genetic Counselor Phone Draw Date: Gestational Age at Draw: Fetal gender by ultrasound: [ ] Male [ ] Female [ ] Ambiguous Patient’s current weight __________ lbs (or) _______ kgs Patient’s height ___________inches (or) _______ cm weeks [ ] Unknown days Is the patient carrying more than one fetus, or is there a known twin demise?   Yes*   No   Unknown Is the patient.

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