Non-Invasive Prenatal Paternity (NIPP)/Peekaboo Client Intake Form

Non-Invasive Prenatal Paternity (NIPP)/Peekaboo Client Intake Form
Section 1 - Service Selection
Which service are you requesting?
Section 2 - Client Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secure Email Address
example@example.com
Preferred Method of Contact
City & State

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 3 - Pregnancy Eligibility Questions
How many weeks pregnant are you?
Is this a single baby pregnancy?
Have you had a recent blood transfusion or transplant?
Is the alleged father available for collection?
Section 4 - Participant Information
For NIPP:
Mother Full Name

First NameLast Name
Alleged Father Full Name

First NameLast Name
Photo ID
For Peekaboo:
Mother Full Name

First NameLast Name
Photo ID
Section 5 - Collection Preferences
Preferred Collection Type
Section 6 - Scheduling Availibility
Select preferred appointment time windows
Preferred Days
*Evening and weekend appointments are subject to collector availability and may require an additional fee. If selected, we will contact you to confirm availability and pricing before scheduling.
Section 7 - Acknowledgements
Testing Coordination Acknowledgment
Prenatal & Informational Testing Acknowledgment
Electronic Communication & Secure Results DeliveryConsent
Signature
Client Full Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Non-Invasive Prenatal Paternity (NIPP)/Peekaboo Client Intake Form

Section 1 - Service Selection

Section 2 - Client Information

Section 3 - Pregnancy Eligibility Questions

Section 4 - Participant Information

Section 5 - Collection Preferences

Section 6 - Scheduling Availibility

Section 7 - Acknowledgements