Source folder: SOPs
Source file: Turn this into SOP-Prenatal COC Form - Legal Tests Only.pdf
File type: PDF document
First Name (Please print clearly) Middle Initial Last Name
Date of Birth SSN Last 4 Digits Client History: (Please check applicable)
Have you had a blood transfusion within the
Race: (Please check one) Form of Photo ID Used: (Please check one) past week? c Yes c No
c Caucasian c Hispanic c Black c Asian c Driver's License c Military ID Have you ever had a bone marrow or stem
c Other (specify): ______________________________________ c Recent Photo cell transplant? c Yes c No
REHTOM
Case #: _______________________
Please print clearly. Entire box must be completed for each party collected.
I, the undersigned, attest that the information appearing on the form is correct and true to the best of my knowledge. I, the undersigned, certify the I have read and
I agree to the Terms and Conditions printed on the back of this form.
Signature of Mother or Legal Custodian*: ___________________________________________________________________________________ Date: ____________________________
*Legal Custodian's signature is required only if the Mother is under 18 years of age or a legally incompetent adult.
First Name (Please print clearly) Middle Initial Last Name
Date of Birth SSN Last 4 Digits Client History: (Please check applicable)
Have you had a blood transfusion within the
Race: (Please check one) Form of Photo ID Used: (Please check one) past week? c Yes c No
c Caucasian c Hispanic c Black c Asian c Driver's License c Military ID Have you ever had a bone marrow or stem
c Other (specify): ______________________________________ c Recent Photo cell transplant? c Yes c No
Collector Statement Collection Facility Information
I certify that I have properly identified the parties and have collected, packaged and Facility: ____________________________________________________________________________________
sealed the specimen(s) and have witnessed the signatures. I affirm, under penalties
for perjury, that no tampering with the specimen(s) occurred while under my control. Phone: ____________________________________________________________________________________
Address: __________________________________________________________________________________
Collector's Signature: ________________________________________________________________
Collector: (Printed Name) __________________________________________________________________ C/S/Zip: ___________________________________________________________________________________
Collection Date: ________________________ Time: ________________ c AM c PM Country: ___________________________________________________________________________________
REHTAF
DEGELLA
Prenatal Identification Form
LAB USE ONLY
Chain of Custody
Corporate Partner: __________________________________________________________
Address: ______________________________________________________________________
One DDC Way - Fairfield, OH 45014 C/S/Zip: _______________________________________________________________________
1-800-929-0815 - 1-800-363-1707 (fax)
Phone: _______________________________ Fax: _______________________________
Email: __________________________________________________________________________
I, the undersigned, attest that the information appearing on the form is correct and true to the best of my knowledge. I, the undersigned, certify the I have read and
I agree to the Terms and Conditions printed on the back of this form.
Signature of Alleged Father or Legal Custodian*: _________________________________________________________________________ Date: ____________________________
*Legal Custodian's signature is required only if the Alleged Father is under 18 years of age or a legally incompetent adult.
TERMS & CONDITIONS ON BACK
COC-4029-CA 180302-DF
Terms and Conditions
I acknowledge, consent and agree to the following: