PATIENT INFORMATION

First Name:
Last Name:
Date of Birth (DD/MM/YYYY):
Gender:
Ethnicity (required for correct test interpretation):
Email Address:
Country:
City
P.O. BOX:
Postal code:
Delivery Location (Town/City):
Mobile/Telephone:

PARENT INFORMATION (IF APPLICABLE)

Mother's Name (Last, First):
Mother's Date of Birth (DD/MM/YYYY):
Father's Name (Last, First):
Father's Date of Birth (DD/MM/YYYY):

SAMPLE INFORMATION

Specimen Type:

TEST DETAILS

Please indicate the individuls undergoing the test:
Patient Only
Trio testing - testing of the father, mother, and child
Couple

ORDERING PHYSICIAN

First Name:
Last Name:
KMPDB No:
Email Address:
Country:
City
P.O. BOX:
Postal code:
Delivery Location (Town/City):
Mobile/Telephone:

RESULTS DELIVERY

Please indicate the preferred method for delivery of results. Choose all that apply
Email
Courier
Telephone
Confirmation of Informed Consent and Medical Necessity for Genetic Testing

By ticking this box, I certify that I am a licensed medical professional or his/her representative or a genetic counselor authorized to order genetic testing. My signature further acknowledges the patient has been supplied information regarding genetic testing and has been informed about the purpose, limitations and possible risks. The patient has been given the opportunity to ask questions about this consent and seek outside genetic counseling. The patient has given consent for genetic testing to be performed and the signed consent form is on file. I confirm that this testing is medically necessary for the specified patient, and that these results will be used in the medical management and treatment decisions for this patient. I confirm that the patient has been informed and hereby authorizes (i) Baby Genes Inc to release information concerning their testing to their insurer in order to obtain reimbursement for the testing services; (ii) Baby Genes Inc to be paid directly by the insurer for services rendered; and/or if applicable (iii) Baby Genes Inc or its affiliates to be the patient’s designated representative for the purpose of appealing any denial of insurance benefits. I confirm the patient fully understands they are legally responsible for sending Baby Genes Inc any and all of the money that they receive directly from their insurance company in payment for this testing.