Client Referral Form

Your agency or clinic*

Patient type*

Donor referral details

State (at time of consult)

Please note that we are unable to facilitate genetic testing for donors located in Pennsylvania or outside the United States due to legal regulations. Testing must be provided in an alternative fashion for these cases.

Genetic testing desired

Carrier screening (default saliva-based Natera panel of 445 conditions for egg and sperm donors)Carrier screening (blood-based Natera panel of 445 conditions for egg and sperm donors); please note that there is an additional blood draw chargeCarrier screening (custom panel choice, please share details below)Karyotype; please note that there is an additional blood draw charge

Custom carrier screening panel details (your request will be reviewed by the team for feasibility before a custom panel can be ordered)

Donor's name

First NameLast Name

Donor's code

Donor's email address

Donor's phone number

Billing type*

Intended parent details (for billing purposes)

*Please note that we will contact the donor to arrange scheduling once we receive payment from the intended parent when this billing option is chosen.

Do you want us to reach out to the patient to schedule?

Patient's name

First NameLast Name

Patient's email address

Patient's phone number

Please upload the following potential documents for our review: profile information, full carrier screening reports/details, genetic risk assessment for donors (even if completed by Advocate Genetics), karyotype, medical records, etc.

Please upload the following potential documents for our review: profile information, full carrier screening reports/details, genetic risk assessment for donors (even if completed by Advocate Genetics), karyotype, PGT results, medical records, etc.

DO ANY OF THE FOLLOWING APPLY? (if yes, a more detailed consultation may be required and the associated appointment fee may vary based on the scope of the discussion)

Intended Parent(s) and Donor are carriers for the same conditionPGT-M DiscussionComplex family history for the Intended Parent(s)More in-depth discussion about a specific condition or testing

IMPORTANT: If additional screening or an unmasked gene revealed a condition the donor carries, please attach the additional report here.

Comments (special requests or anything additional we should know about the case):

Our standard turn around time on session summaries is 4 business days. A rush (1-2 business day turn around time) is available for an additional $50 fee. If we are unable to accommodate this request we will be in touch. The fee will only be charged if we are able to rush your summary. Please check the box below if a rush is needed.

Rush request

Optional: After your referral is submitted, you will receive a confirmation email that includes only the non-PHI portions of the information entered. In this box, please list the intended parents' initials so you can track the date your organization submitted the referral.

Person submitting form:*

First NameLast Name

Contact email for person submitting form:*