Patient Details	Ethnic Group: c Caucasian	c Aboriginal	c Asian	c African-Caribbean	
Family Name
Patient Demographics.Surname
	Given Name(s)
Patient Demographics.First Name
	
Date of Birth
Patient Demographics.DOB
	UR Number
Patient Demographics.Ur No
	Medicare Number
Patient Demographics.Medicare Number
Patient Demographics.Medicare Expiry Date
	
Address 
Patient Demographics.Full Address
	
Suburb
Patient Demographics.Suburb
	State

	Postcode
Patient Demographics.Postcode
	
Clinical Details – Mandatory	
c First Trimester Screen  c Second Trimester  c Neural Tube Defect only  c Omega-3 status (SAHMRI)
EDD/LMP EDD/LMP  Cycle length (days) ______ Maternal weight (Kgs) ______
GA Clinical weeks + days 			 on ____/____/____  
GA Ultrasound weeks + days 	 on____/____/____  	Crown-rump length (CRL) mm 	  on ____/____/____  
Pregnancy: c Singleton c Twins c Triplets	IVF:	c Yes	c No	

Age at egg retrieval/age of egg donor 	
Pregnancy complications: Diabetes (IDMM only) c Yes c No  Smoker c Yes c No  Previous c T21 c T18/13

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:
c a private patient in a private hospital or approved day hospital facility
c a private patient in a recognised hospital
c a public patient in a recognised hospital
c an outpatient public of a recognised hospital
c 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.
c Do Not send to My Health Record
✗	 Date 	/	/	
Patient signature
Practitioner’s Use Only

(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	c SAMSAS risk assessment calculation not required	
Name: Treating Doctor.Name
Provider No: Treating Doctor.Provider Number
Address: Treating Doctor.Address
Tel: Treating Doctor.Phone       Fax: Treating Doctor.Fax
Email: Treating Doctor.E-mail
Signature: 
Request date:Miscellaneous.Date	Copy of report to:
Name:
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	
Where to have your blood taken (other than by your doctor)

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