PANORAMA INTERNATIONAL REQUISITION

PATIENT INFORMATION

First Name

Lastname

Date of Birth

Address

City

Country

Telephone

Enter your email

Weight

Height

Expected Due Date

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.

IVF conceived pregnancy: Age of mother at egg retrieval:

Ongoing twin pregnancy:

Monochorionic

Dichorionic

Don’t Know

Surrogate or Egg donor pregnancy

DATE of SIMPLE COLLECTION

CLINIC INFORMATION

Clinic Name

Telephone

Natera® LIMS ID

Ordering Clinician Name

SCREENING OPTIONS

SELECT SCREENING OPTION BELOW

PANORAMA PRENATAL PANEL Chromosomes 13, 18, 21, X & Y; Triploidy

PANORAMA PRENATAL PANEL + 22q11.2 DELETION Chromosomes 13, 18, 21, X & Y; Triploidy; 22q11.2 deletion

PANORAMA EXTENDED PANEL Chromosomes 13, 18, 21, X & Y; Triploidy; 22q11.2 deletion PLUS four microdeletions

PANORAMA BASIC PANEL (LIMS ID: 13479)

Check to add fetal sex to report (available with any screening option above)

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.