request

REQUEST FORM

Reprogenetics Latinoamerica

Calle Aricota 106 suite 202, Chacarilla, Santiago de Surco, Lima-Peru

E-mail: lab-PGD@reprogenetics.com.pe or Fax: (511) 271-6776

Clinical information of patient and IVF:

Patient name:
Patient date of birth :
Husband name :
Husband date of birth :
Doctor requesting PGD :
Doctors signature :
Donor used name :
Donors age :

Anticipated appointment for ovocyte obtaining

Referred by Center :
Center Address :
Center City :
Center Departamento :
Center Postal Code :
Center Country :
Main Phone:
Main Fax :
Emergency Contact name :
Cellular Phone :

PGD motivated by (mark does you need) :

Requested Test :

Aneuploidies 12 Chromosomes (X, Y, 8, 13, 14, 15, 16, 17, 18, 20, 21 & 22 )
Aneuploidies 9 chromosomes ( X, Y, 13, 15, 16, 17, 18, 21 & 22 )
Extra chromosome (please indicate what chromosome)
Aneuploidies (5 chromosome) in addition to reciprocal translocation (13, 16, 18, 21 & 22)
Sex selection (related to X)
Aneuploidies 5 chromosomes ( X, Y, 13, 18 & 21 )
Robertsonian Translocation
Reciprocal translocation / Pericentrical Inversion
Genetic disorder
Other
Explain if other

Important notice: To program and confirm your PGD appointment, Reprogenetics must receive this request form completely fill with your request letter.

Note: All translocations and genetic disorders require a genetic consultation and a extended preparation for the test, this a six to eight weeks process.

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

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