Home

Clinical Services

Cytogenetic
Testing

Forms &
Resources
About GLG
Contact Us
Site Map
 

Maternal Serum Screening
Requisition Form

Great Lakes Genetics
2323 North Mayfair Road l Milwaukee, WI 53226-1504
Office: (800) 647-0089 l Laboratory: (414) 475-5904
FAX: (414) 475-7220

Please complete all information and return form to GLG. Feel free to call our lab with any questions.
Test Requested: BEST Test (combines First Trimester, Triple Screen and Quad Screen) [10-22 weeks]
Quad Screen [14-22 weeks]
Triple Screen [14-22 weeks]
AFP only
Date Blood Drawn
(mm/dd/yyyy):		  
Medical Record #:  
Client Information
Physician Name:  
Phone:  
FAX:  
Clinic/Laboratory:  
Patient Information

Patient Name
(Last, First, MI):

  
Date of Birth (mm/dd/yyyy):  
Ethnic Origin: Caucasian
Asian
Hispanic
African American
Native American Indian
Far Eastern
Other: _______________________
Maternal Weight (lbs.):  
Is Patient insulin dependent diabetic?: Yes No
LMP date:  
EDC date: ______________ by US or LMP
Gestational Age on date drawn: ___________ weeks ___________ days
Nuchal fluid measurement (mm):  
Twins: Yes No
CVS done: Yes No
Other ultrasound findings:  
Problems with this pregnancy:

 

Specimen Requirements
 2 ml of serum separated, poured off from red blood cells and frozen

A Pregnancy Outcome form will be sent in the month that the baby is due. Thank you in advance for taking the time to complete and return the form to Great Lakes Genetics.

DO NOT FILL IN THIS SECTION
GREAT LAKES GENETICS LAB USE ONLY
GLG LAB # ___________  
AFP ____________ ng/mL HCG ____________ mIU/ml
UE3 ____________ ng/mL FB-HCG ____________ ng/mL
PAPP-A ____________ mIU/mL  
updated 12/05