高通量基因测序产前筛查NIPT-plus知情同意书

__________________________Р家族遗传病:Р□无Р□有Р______________________________________________Р夫妻双方染色体核型: □无Р□有Р______________________________________________Р产前检查Р妊娠情况:Р□单胎Р□双胎Р□其他:_________________________________Р试管婴儿:Р□否Р□是Р超声检查:Р□未见异常Р□胎儿结构异常:_________________________________________________Р□软指标高风险:_________________________________________________Р□介入性手术治疗:_______________________________________________Р□其他:_________________________________________________________Р血清筛查:Р□未做Р□已做,风险值:21-三体:1/___ 18-三体:1/____ NTD___Р预约介入性穿刺手术: □无Р□已预约:________年_____月_____日Р临床诊断:_______________________Р其他信息Р细胞治疗:Р□否Р□是Р_____________________________________________Р肿瘤患者:Р□否Р□是Р_____________________________________________Р一年内异体输血:Р□否Р□是Р_____________________________________________Р特殊情况备注:Р送检医院:Р申请医生:Р申请日期:Р年Р月Р日