information

INFORMATION FORM

BASIC INFORMATION FOR PGD OF

TRANSLOCATIONS AND GENETIC DISORDERS

This form must be included with the blood sample for PGD.

IVF information from the Clinic:

Requesting Doctor :
Reference Center :
Center Address :
Center City :
Main Phone :
Main Fax :
Direct Doctor Phone :
E-mail :

Patient information :

Name of the carrier of the translocation or genetic disorder :
husband karyotype or mutation:
Wife karyotype or mutation:
Genetic Laboratory that analyzed the karyotype or mutation:

Sample information :

Sample type :
Sample collecting date :

Please send this form and the blood sample to:

Reprogenetics Latinoamerica

Calle Aricota 106 Suite 202

Chacarilla - Surco

Lima - Peru

Important notice: PGD for translocations and genetic disorders require a genetic consultation and a extended preparation for the test. For consultation get in touch with Blgst. Paul Lopez to:

phone (511) 272-2444 or Fax: (511) 271-6776

or Cell : (511) 9827-8984 or write an Email to:

lab-PGD@reprogenetics.com.pe

Click here to download the form in PDF format

Click here to download the form in MSWord format