PANORAMA INTERNATIONAL REQUISITION

PLEASE COMPLETE ALL FIELDS IN ENGLISH. REQUISITION FORMS SUBMITTED WITH MISSING INFORMATION MAY CAUSE A DELAY IN TURNAROUND TIME OF THE TEST.

PATIENT INFORMATION

Patient must be at least 9 weeks gestation. 22q is not available for dizygotic twins or egg donors. Extended panel is not available for twins or egg donors. For twin or surrogate pregnancies, check all that apply. We do NOT accept vanished twin, multiple gestation with more than 2 fetuses, or twins conceived using a surrogate or egg donor.

DATE of SIMPLE COLLECTION

CLINIC INFORMATION

SCREENING OPTIONS

SELECT SCREENING OPTION BELOW

DISPOSITION OR RETENTION OF SAMPLES

Laboratory (Reseller) represents and confirms that the patient has given informed consent compliance with applicable law to Natera’s following sample disposition or retention policy: PATIENT UNDERSTANDS AND CONSENTS THAT: (i) her/his sample will be sent to the United States for performance of the test; (ii) Natera may retain the patient’s leftover, de-identified samples to use for medical and technology advancement, research & development, product validation and quality assurance, independently or collaboration with third-party partners, either in or outside the United States; and (iii) patient and patient’s heirs will not receive any payments, benefits, or rights to any resulting products or discoveries.