Scribd Logo
Upload

Welcome to Scribd!

  • Form 11

    Uploaded by

    Nurul Huda Khan
    133 views1 page
    This document is a requisition form for a maternal serum screening test from Dr. Lal PathLabs Ltd., a national reference laboratory in New Delhi, India. The form requests patient information like name, date of birth, last menstrual period, gestational age by ultrasound, nuchal thickness measurement, and risk factors. It allows the referring doctor to select Screen 2, 3, or 4 and provides fields for patient details like weight, diabetes and smoking status, gestation type, race, use of IVF, and history of neural tube defects or trisomies in previous pregnancies.

    Original Description:

    Form 11 of Lal Path Labs

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a requisition form for a maternal serum screening test from Dr. Lal PathLabs Ltd., a national reference laboratory in New Delhi, India. The form requests patient information like name, date of birth, last menstrual period, gestational age by ultrasound, nuchal thickness measurement, and risk factors. It allows the referring doctor to select Screen 2, 3, or 4 and provides fields for patient details like weight, diabetes and smoking status, gestation type, race, use of IVF, and history of neural tube defects or trisomies in previous pregnancies.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    133 views1 page

    Form 11

    Uploaded by

    Nurul Huda Khan
    This document is a requisition form for a maternal serum screening test from Dr. Lal PathLabs Ltd., a national reference laboratory in New Delhi, India. The form requests patient information like name, date of birth, last menstrual period, gestational age by ultrasound, nuchal thickness measurement, and risk factors. It allows the referring doctor to select Screen 2, 3, or 4 and provides fields for patient details like weight, diabetes and smoking status, gestation type, race, use of IVF, and history of neural tube defects or trisomies in previous pregnancies.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    Doc No.

    : LPL/R/QF/2712

    Dr Lal PathLabs Ltd.


    National Reference Laboratory: Sector 18, Block E, Rohini, New Delhi 110 085
    Tel: 91-11- 3040 3210, 3988 5050. Fax: 91-11-3040 3204
    E-mail: lalpathlabs@lalpathlabs.com Website: www.lalpathlabs.com

    MATERNAL SERUM SCREEN 2 /3 /4 REQUISITION FORM


    (Form-11) (PLEASE TICK REQUESTED TEST)

    Patient's Name : ............................................................................ Sample Collection Date: ........................

    Lab No. : .................................................................................

    Tel. No. .................................................. Ref. Doctor's Name . ..................................................

    D.O.B.(Day/Month/Year) : .................................................................................

    L.M.P.( Day/Month/Year) : .................................................................................

    Gestational age by Ultrasound (in weeks/days) : .............................. Date of Ultrasound ..............................

    Nuchal thickness (in mm) : ...................................................................CRL (in mm).....................................

    Nasal bone (Present / Absent) : .......................................................................................................................


    (Attach photocopy of Nasal Bone (Present / Absent) Ultrasound report) : .....................................................

    Weight : .................................................................................

    Diabetic Status : No / Yes


    (On Insulin)
    Smoking : No / Yes
    Gestation : Single / Twins
    Race : Asian / African Caucasian Others
    IVF : No / Yes
    : If yes - Own eggs / Donor eggs

    If yes (Provide D.O.B. of donor)

    Patient sample : Initial / Repeat

    H/O Neural Tube defect in Previous Pregnancy No Yes

    H/O Trisomy 13/18/21 in Previous Pregnancy No Yes

    You might also like