Natalis Test Requisition For Providers
Lab Test Ordered
Natalis: Includes 166 disease genes, 10 pharmacogenetic genes
What is the primary reason for testing?
Interested in additional screening for healthy child
Child is suspected of having an inherited condition and seeking a diagnosis
Patient Information
Patient/Child Last Name
Patient/Child First Name
Client MRN
Patient DOB (MM/DD/YYYY)
Biological Sex
Male
Female
Legal Guardian Information
Guardian Last Name
Guardian First Name
Phone Number
Address
City
State
Zip Code
Email
Patient and Family Medical History
Ethnicity of the Child (check all that apply)
African American
Ashkenazi Jewish
Caucasian
Cajun/French Canadian
East Asian
Hispanic Caribbean
Mizrahi Jewish
North African
North/Central American
Sephardic Jewish
South American
South Asian
Sub-Saharan African
Other
Specify ethnicity
Were there any abnormal prenatal tests during pregnancy? (check all that apply)
Abnormal ultrasound
Fetal AFP analysis
Fetal chromosome analysis
Fetal chromosomal microarray
Maternal serum screening (First Trimester Screening, AFP, Quad Screening, etc)
Noninvasive prenatal testing (NIPT)
None
Not sure
Do the biological parents/relatives have any of the conditions tested in this screening?
Yes
No
Not sure
What is the condition name(s)?
Which family member has the condition(s)?
Has the child ever had a bone marrow or stem cell transplant?
Yes
No
Has the child had routine newborn screening?
Yes
No
Not sure
I
s the child generally healthy with no major medical problems and not under the care of a medical specialist?
Yes
No
Choice C
Exceptions: Optometrist, Dentist, Allergist, or specialist treating a traumatic injury
Is the child currently receiving any medications other than antibiotics?
Yes
No
Patient Specimen Information
Patient Specimen Type
Blood
Saliva
Cheek Swab (*preferred*)
Date of Collection (MM/DD/YYYY)
ICD-10 Diagnosis Code(s)
Z13.9: Encounter for screening, unspecified
P09: Abnormal finding on neonatal screening
Z13.228: Encounter for screening for other metabolic disorders
Other
Specify ICD10 code
Parental Specimen Information
Please also provide specimen for one biological parent, if possible.
Parent providing sample
Biological Mother
Biological Father
N/A: Biological parent not available
Parent Specimen Type
Blood
Saliva
Cheek Swab (*preferred*)
Date of Collection (MM/DD/YYYY)
Financial Responsibility
Select patient pay or institutional billing below.
For patient pay orders, Sema4 will send the guardian an email to complete payment online once specimen is received by the lab.
Patient Pay
Institutional billing
Coupon/Discount Code
[insert synergenomics code here]
Referring Provider Information
Provider Name (First, Last, Credential)
eg. John Smith, MD
Provider Practice Name
Provider Practice Address
Provider City / State / Zip Code
PROVIDER SIGNATURE CONSENT:
I certify that this patient (and/or their legal guardian, as necessary) has been informed of the benefits, risks, and limitations of the laboratory test(s) requested. I have answered this person's questions. I have obtained a signed information consent from this patient or their legal guardian for this testing in accordance with applicable laws and regulations, including N.Y. Civil Right Law Section 79-L, and will retain this consent in the patient's medical record.
Yes, I have read and agree.
Provider Consent Date (MM/DD/YYYY
)
Patient and Guardian Consent
Consent must be collected on all individuals who are submitting a sample to sema4. Please also print and complete
Patient consent
and
Parent consent
and submit with the specimen.
Contact Information