PATIENT HISTORY FORM FOR NON-INVASIVE PRENATAL TESTING (NIPT) Preview on Page 1

PATIENT HISTORY FORM FOR NON-INVASIVE PRENATAL TESTING (NIPT) 2026

The document is a Patient History Form for Non-Invasive Prenatal Testing (NIPT) provided by Mercy Diagnostics. It collects essential patient information, including demographics, medical history, and reasons for testing. The NIPT aims to screen for chromosomal abnormalities such as Down syndrome and other conditions using maternal blood samples. It outlines the test's purpose, potential results, limitations, and informed consent requirements. The document emphasizes that NIPT is a screening tool and not a diagnostic test, advising further testing if results indicate high risk.

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Click ‘Get Form’ to open the PATIENT HISTORY FORM FOR NON-INVASIVE PRENATAL TESTING (NIPT) in our editor.
Begin by entering your Patient Name and Date of Birth at the top of the form. This information is crucial for identification.
Fill in the Physician/Genetic Counselor's details, including their Phone and FAX numbers, ensuring accurate communication.
Indicate the Draw Date and Gestational Age at Draw. Select the Fetal gender by checking the appropriate box: Male, Female, or Ambiguous.
Provide your current weight and select your race from the options provided. If you are carrying more than one fetus, indicate this as well.
Check all applicable indications for testing. This section helps clarify why you are seeking NIPT.
If applicable, include the father’s name and date of birth for additional context regarding testing requirements.
Review all sections carefully before submitting to ensure accuracy. Use our platform's features to save or share your completed form easily.

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Do you need a requisition for a NIPT test?

Yes, you need a requisition. It can come from your family doctor.

What is a non invasive prenatal screening NIPT?

NIPT testing costs vary. Most health insurances cover most (if not all) of the cost. Many cover at least a portion. Check with your insurance provider before testing to be sure.