CLARITY Test Ordering Form

TEST ORDERING FORM

Patient name
Date of birth	Date of birth (DD/MM/YYYY)
Tube ID *	Unique sample tube identifier
Type of sample	BLOOD

Week of miscarriage

Blood sampling date

Clinician's name
Clinic authorization code	Celvia CC provides each clinic with a unique ordering code after a service contract has been signed.
Clinician's phone number
Clinician's e-mail

I confirm that the blood sample was collected immediately after the ultrasound examination and that retained pregnancy tissue was present in the uterus at the time of sampling. I confirm that I am ordering the CLARITY test at the patient’s request. I confirm that the patient has been informed about the purpose, possible results, and limitations of the test, including that it is a screening test and not a diagnostic procedure. I confirm that the patient has provided informed consent and that the information provided is accurate and complete.