Patient Information form for Preimplantation Genetic Diagnosis pre-clinical Work-up

Simply complete the few fields on this form.

In other way, download the Patient Information form in PDF format. Then fax the form and the DNA diagnostic report(s) that define the gene mutation (if you have it) to our fax number +390664492025 or e-mail it to the following address: biricik@laboratoriogenoma.it 
Call our Contact center +3906164161500 (12 linee PBX) if you have any questions.

*** Required information

Patient :
By Convention, the Woman		 First ad Last Name

Date of Birth (dd/mm/yyyy)
(Has Gene Mutation)
(Heterozygote)
(No Gene Mutation)
Patient :
The Male Partner		 First ad Last Name

Date of Birth (dd/mm/yyyy)
(Has Gene Mutation)
(Heterozygote)
(No Gene Mutation)
Affected Relative1
If any		 First ad Last Name

Date of Birth (dd/mm/yyyy)
(Has Gene Mutation)
(Heterozygote)
(No Gene Mutation)
Affected Relative2
If any		 First ad Last Name

Date of Birth (dd/mm/yyyy)
(Has Gene Mutation)
  (Heterozygote)
  (No Gene Mutation)
Unaffected Relative3
If any		 First ad Last Name

Date of Birth (dd/mm/yyyy)
  (Has Gene Mutation)
  (Heterozygote)
  (No Gene Mutation)
Unaffected Relative4
If any		 First ad Last Name

Date of Birth (dd/mm/yyyy)
(Has Gene Mutation)
(Heterozygote)
(No Gene Mutation)

Genetic Disorder of Concern
(e.g. Cystic Fibrosis, Fragile X)


Indication for PGD:
(e.g. Cystic Fibrosis, Fragile X, Beta Thalassemia combined with HLA matching)


Other Indication:
(e.g. Advanced maternal age, recurrent miscarriages, repeated implantation failure, PGS, Chromosomal Translocation)


Case Summary:
(Brief description of the case)


Pedigree:

Request:
 

Mutation(s) screening
PGD Set Up (single gene defect)
PGD Set Up (HLA matching)
PGD Set Up (Aneuploidy screening)
PGD Set Up (Translocation)
Other (please specify)

Clinic Name


Address


PGD Coordinator with whom we can communicate


Phone (Or Work Mobile)


Fax


Best Email ***
VERY important for us to interact with you and coordinate your case


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