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Solicitare analize Centogene
Patient's initials:
Date of birth:
›Requested test*:
For singleton pregnancy:
CentoNIPT® for aneuplodies in chromosomes 21, 18, 13 and gonosomal aneupoidies
For twin pregnancy:
CentoNIPT® for aneuplodies in chromosomes 21, 18, 13 and gonosomal aneupoidies
Reporting on fetal gender1,2?
YesNo
›Clinical information*:
Gestational age at sample collection:
Maternal weight:
Date of sample shipment:
Maternal height:
Normal pregnancy
Abnormality of fetal movement
Increase nuchal translucency
Short fetal humerus length
IVF or egg donor pregnancy (specify in further clinical information)
Abnormal ultrasound
Advanced maternal age
Positive serum screen
History of chromosome aneuploidies (specify in further clinical information)
›Further clinical information (e.g. family history, affected siblings, additional clinical symptoms):

NIPT Streck tube number*:
Date of sample draw*:
›Patient Information:
Last Name:
First Name:
Date of Birth:
Sex:MaleFemaleOther
Your Reference Number:
Sample Collection Date:
›Physician or Laboratory:
Reporting address:
Name of Physician:
Clinic Name:
Department:
Street:
Town:
Postal Code:
Country:
Phone:
Fax:
E-mail:
›Additional Report Recipient:
Name of Physician:
Clinic Name:
Department:
Street:
Town:
Postal Code:
Country:
Phone:
E-mail:
I hereby confirm that the patient consented to forward the medical report to this additional report recipient.
Billing:
›Promo Code - If applicable:

CENTOGENE Quotation No.:
Invoice to:PatientInstitutionInsurance* - *Please attach cost coverage authorization
Company/Last name:
Department/First name:
Street:
Town:
Postal Code:
Country:
Phone:
VAT ID (mandatory for institutional customers in the EU):
E-mail:

Accept Termenii și Politica de Confidențialitate.

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