CLARITY Test Ordering Form

CLARITY TEST ORDERING FORM

First name and surname of the patient
Patient personal ID or date of birth
Sample ID	Unique sample ID identifier
Type of sample	BLOOD

Pregnancy week

Date of blood sampling

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. I confirm that the patient has provided informed consent and that the information provided is accurate and complete.