NIPT Informed Consent Form
Use this form to provide your details, review NIPT screening information, and confirm your decision to proceed.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Best Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pregnancy and Test Context
Estimated due date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gestational age (weeks and days)
Reason for requesting NIPT / clinician recommendation
*
Preferred result delivery method
*
Phone call
Secure message
In-person review
Other
Consent Acknowledgment
Consent Statement
I acknowledge the following about NIPT
*
NIPT is a screening test and not a diagnostic test
Abnormal or unclear results may require follow-up testing
I have had the opportunity to ask questions and receive answers
Patient Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Submit Form
Should be Empty: