Patient Details					Ethnic Group: <PtEthnicity>	
Family Name
<PtSurname>	Given Name(s)
<PtFirstName>	
Date of Birth
<PtDoB>	UR Number
<UR Number (If known)>	Medicare Number
<PtMCNo>	
Address
<PtStreet>	
Suburb
<PtCity>	State
<PtState>	Postcode
<PtPostcode>	
Clinical Details – Mandatory <Clinical Details – Mandatory>	
<First Trimester Screen> First Trimester Screen	
<Second Trimester> Second Trimester	
<Neural Tube Defect only> Neural Tube Defect only	
<Omega-3 status (SAHMRI)> Omega-3 status (SAHMRI)	

EDD/LMP: <LMP>	
Cycle length (days): <Cycle length (days)>	
Maternal weight (Kgs): <Maternal weight (Kgs)>	

GA Clinical weeks + days	
	<GA Clinical weeks + days> on <GA Clinical weeks + days date:>	

GA Ultrasound weeks + days	
	<GA Ultrasound weeks + days> on <GA Ultrasound weeks + days date:>	

Crown-rump length (CRL) mm	
	<Crown-rump length (CRL) mm> on <Crown-rump length (CRL) mm date:>	

Pregnancy: <Pregnancy:>	
<Singleton> Singleton  <Twins> Twins   <Triplets> Triplets   	IVF:  <IVF>    	Age at egg retrieval/age of egg donor: <Age at egg retrieval/age of egg donor>	

Pregnancy complications: <Pregnancy complications:>	
Diabetes (IDMM only) <Diabetes (IDMM only)>	Smoking status: <SmkStatus>  	Previous <Previous T21> T21  <T18/13> T18/13	

Name of Imaging Practice:	
<Name of Imaging Practice:>	

For first trimester screening risk assessment an Ultrasound request form is required for Nuchal Translucency, 11-14w0d.	

Patient status at the time of the service or when the specimen was collected: <Patient status at the time of the service or when the specimen was collected:>
<a private patient in a private hospital or approved day hospital facility> a private patient in a private hospital or approved day hospital facility
<private patient in a recognised hospital> a private patient in a recognised hospital
<public patient in a recognised hospital> a public patient in a recognised hospital
<an outpatient public of a recognised hospital> an outpatient public of a recognised hospital
<an outpatient private of a recognised hospital> an outpatient private of a recognised hospital

Privacy Disclosure SAMSAS requires the personal information contained in this request form for the purpose of Risk assessment and Program Audits. SAMSAS may therefore request copies of ultrasound and cytogenetic reports from your doctor in order to complete its testing and audits.	
Medicare Benefits (Section 20A of the Health Insurance Act 1973). I offer to assign my right to the approved pathology practitioner who will render the requested pathology service(s) and any eligible pathologist determinable service(s) established as necessary by the practitioner.
<Do Not send to My Health Record> Do Not send to My Health Record

Patient Signature				Date	<TodaysDate>
Practitioner’s Use Only
<If the patient can't sign the Medicare Benefits section, enter the reason.>
(Reason patient cannot sign)	

5-10ml CLOTTED BLOOD SAMPLE Gel or plain tube - no anticoagulant
First trimester blood sample 9-14w0d Second trimester blood sample 14w1d-20w6d
I have verified FULL NAME, DOB and URN on the sample label and request form verbally with the patient and/or checking the patient’s ID band.

Collector’s Signature ___________________________	Specimen Collected	/         /		      :	Hrs	

Requesting Doctor		<SAMSAS risk assessment calculation not required> SAMSAS risk assessment calculation not required	

Name:			<DrName>
Provider No:		<DrProviderNo>
Address:			<DrStreet>
			<DrCity> <DrPostcode> <DrState>
Tel:  <DrPhone>		Fax:  <DrFax>
Email:			<DrEmail>
Signature:
Request Date:		<TodaysDate>	
Copy of report to:
Name:		<Copy of report to name:>
Address:		<Copy of report to address:>	

Deliver to: South Australian Maternal Serum Antenatal Screening (SAMSAS) Program
SA Pathology, Specimen Reception Area, Level 3, Royal Adelaide Hospital. Port Rd ADELAIDE SA 5000.
T (08) 8161 7285 	F (08) 8161 8085 		samsas.program@health.sa.gov.au 		www.wch.sa.gov.au/samsas.html	

Enquiries 8222 3000									www.sapathology.sa.gov.au	

PUB-0452 v11 Published 15/1/21													

Where to have your blood taken (other than by your doctor)

	SA	SA Pathology Patient Centres						8222 3000 (Metropolitan)
		Visit www.sapathology.sa.gov.au for your nearest Patient Centre		1800 188 077 (Regional)

	TAS 	Hobart Pathology 							6223 1955
		North West Pathology 							6430 6762
		Launceston Pathology 							6334 3636
		Royal Hobart Hospital (Specialist Clinic) 					6222 8644
		Pathology South 							6166 0150
		Launceston General Hospital 						6348 7690

	NT 	Darwin Pathology 							8922 8076

Privacy Note: The information provided will be used to assess any Medicare benefit payable for the services rendered and to facilitate the proper administration of government health programs, and may be used to update enrolment records. Its collection is authorised by provisions of the Health Insurance Act 1973. The information may be disclosed to the Department of Health and Ageing or to a person in the medical practice associated with this claim, or as authorised/required by law.

	
Enquiries 8222 3000									www.sapathology.sa.gov.au