NATIONAL HAEMOGLOBINOPATHY REFERENCE LABORATORY Molecular Haematology Dr John Old, FRCPath. Director: Dr. Shirley Henderson. PhD. Level 4 Deputy Director: Sample reception: 01865 572769 Sec: 01865 572826 Fax: 01865 572775 Email : . Website: Oxford, OX3 9DU REQUEST FORM: for Prenatal Diagnosis of Haemoglobin Disorders details: Mother’s details: Partner’s Surname: Surname: Forename: Forename Date of birth: Date of birth: Address : Address NHS number: NHS number: Hosp No: Hosp No: GP Name and address: Referred by: Report to: Name Name Address : Address Telephone Telephone INVOICE to be sent to: Fetal Sampling Details Indication of risk………………………… genotype........................................ Mother’s Father’s genotype..................................... Type of samples sent Maternal blood / Paternal blood / CVS / CVS DNA / Amniotic fluid / Fetal Blood (please circle) : Date/time of fetal sample…………………………….. Gestation at sampling: …………………., Cytogentics lab used for cleaning /culturing::………………………………………………………………………………………… Sample and for Information Requirements (full details are in our “information users” guide) Fetal samples: The sample must be sent to a cytogenetics lab for cleaning /culturing before forwarding to us. Parental samples: Fresh EDTA blood samples & FBC/HPLC results should be sent with the PND request form. User Information: Please telephone sample reception to book in the fetal sample before sending. Please indicate to confirm if the mother and partner have given consent for their DNA to be stored and used in Yes / No research and development projects that have been granted ethical approval (please delete as appropriate):
NATIONAL HAEMOGLOBINOPATHY REFERENCE LABORATORY Director: Dr John Old, FRCPath. Molecular Haematology Deputy Director: Dr. Shirley Henderson. PhD. Level 4 Sample reception: 01865 572769 Sec: 01865 572826 Fax: 01865 572775 Email : . Website: Oxford, OX3 9DU REQUEST FORM: for Prenatal Diagnosis of Haemoglobin Disorders Mother’s details: Partner’s details: Surname: Surname: Forename: Forename Date of birth: Date of birth: Address : Address NHS number: NHS number: Hosp No: Hosp No: GP Name and address: Referred by: Report to: Name Name Address : Address Telephone Telephone INVOICE to be sent to: Fetal Sampling Details Indication of risk………………………… Mother’s genotype........................................ Father’s genotype..................................... Type of samples sent (please circle) : Maternal blood / Paternal blood / CVS / CVS DNA / Amniotic fluid / Fetal Blood Date/time of fetal sample…………………………….. Gestation at sampling: …………………., Cytogentics lab used for cleaning /culturing::………………………………………………………………………………………… Sample and Information Requirements (full details are in our “information for users” guide) Fetal samples: The sample must be sent to a cytogenetics lab for cleaning /culturing before forwarding to us. Parental samples: Fresh EDTA blood samples & FBC/HPLC results should be sent with the PND request form. User Information: Please telephone sample reception to book in the fetal sample before sending. Please indicate to confirm if the mother and partner have given consent for their DNA to be stored and used in research and development projects that have been granted ethical approval (please delete as appropriate): Yes / No
prenatal-diagnosis-haemoglobin-disorders.docx