GENETIC TEST REFERRAL FORM for LUCINA

for Birmingham West Midlands Regional GeneticsLaboratory

GeneAdviser Identification Number:

This form must only be used for genetic test orders placed on

Surname / First name(s) / Reg. No. / CG Number
DOB / NHS Number / TypeNHS/Private
Gestation in Weeks when Sample was Taken / Date Sample Taken / Reason for Referral e.g. increased risk, maternal request
Address / Referring Clinician Consultant or GP - Name in full / Medical Specialty
Referral Centre Hospital, practice etc. - Name in full / Ward

Sample instructions

Blood samples should be taken in aStreckTM BCT tube

  1. This tube must contain between 7 and 10ml of blood to allow for testing, aminimum of 7ml of blood is required.
  2. When drawing blood, use a Vacutainer blood draw system without tubing.
  3. After blood is drawn into tube, it is mandatory to mix the tube by gentleinversion 8-10 times
  4. Label the tube with BOTH the patient’s full name and date of birth.
  5. Samples should be sent directly to the West Midlands Regional Genetics laboratoryon day of blood draw. All samples should be accompanied by this completed referral formand thesigned patient consent form(see next page).

West Midlands Regional Genetics laboratory

Birmingham Women’s NHS Foundation Trust

Mindelsohn Way, Edgbaston

Birmingham B15 2TG, United Kingdom

Consent for Lucina NIPT testing at the

West Midlands Regional Genetics Laboratory

NIPT is a new option in prenatal screening for Down syndrome (trisomy 21) and othercommon chromosomal conditions: Edwards syndrome (trisomy 18) and Patau syndrome(trisomy 13).

The procedure of Non-Invasive Prenatal Diagnosis has been explained to me. I understand that

  1. The test identifies more than 99% of fetuses with trisomy 21, 97% with trisomy 18 and 87% withtrisomy 13
  2. A high risk result does not mean that the fetus definitely has one of these conditions. For thisreason follow-up test by an invasive prenatal diagnostic procedure is recommended
  3. If the test result shows a low risk for any of the conditions a small risk remains that the fetus maybe affected
  4. The results of the test will be ready in two weeks
  5. If there is insufficient fetal DNA, a further sample of blood may be required. This will beprocessed in the laboratory at no extra charge. If the follow up test also fails your payment will notbe refunded
  6. Test results will be kept confidential. Anonymised, left over material may be used for researchand service development purposes
  7. This is a private test, not currently funded by the NHS

I authorise for personally identifiable data to be shared, if needed, through a confidentially processwith Verinata Health, Inc. a wholly owned subsidiary of Illumina, Inc. in the USA, in compliance withtheir data protection regulations.

I have read and understand the information above and I understand the results I will get.

Signed______Date______

Print______

Birmingham-GeneAdviser Referral Form v1