Xytex Donor Profile: 5227
|
|
|
- Gary Morrison
- 9 years ago
- Views:
Transcription
1 Xytex Donor Profile: 5227 Basic Version Profile prepared on Tuesday September 20, 2016 For More Information Contact Us Website: Phone:
2 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 2 of 9 General Information Donor ID: 5227 Baby Photo Adult Photo 1980 Marital Divorced Number of Children: Religion: Protestant Occupation: 0 Blood Type: O + Professor of Business Baby Photo Available Adult Photo Available Ethnicity: Swedish, German Audio File: t Available Race: Caucasian CMV NEG Reported Pregnancy: Canadian Compliance: Identity Disclosure: Yes Yes Yes Last Medical History Update: 07/13/2016 Genetic Testing 6 photos available. Over the years, Xytex has expanded genetic testing of donors as genetic knowledge and technology have advanced. As a result, not all donors have been tested for the same conditions or with the same methods. "xygene" donors have undergone the most extensive testing. For more information about genetic testing view our "Genetics Video and FAQs." This donor has been evaluated for carrier status of the listed conditions. A negative result reduces, but does not eliminate, the likelihood of the donor being a carrier. If you are a known carrier of a genetic condition please contact us, and we will provide a copy of the donor's test reports to your physician and/or genetic counselor. Beta-Thalassemia (HBB) Bloom Syndrome (BLM) Canavan Disease (ASPA) Chromosomal Analysis Cystic Fibrosis (CFTR) ; normal complete blood count rmal male karyotype Xytex Donor Profile 5227 Page 2 of 9
3 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 3 of 9 Dihydrolipoamide Dehydrogenase Deficiency (DLD) Familial Dysautonomia (IKBKAP) Familial Hyperinsulinism, ABCC8-Related (ABCC8) Fanconi Anemia Group C (FANCC) Gaucher Disease (GBA) Glycogen Storage Disease Type Ia (G6PC) Joubert Syndrome 2 (TMEM216) Maple Syrup Urine Disease Type 1B (BCKDHB) Mucolipidosis Type IV (MCOLN1) Nemaline Myopathy, NEB-Related (NEB) Niemann-Pick Disease Type A (SMPD1) Niemann-Pick Disease Type B (SMPD1) Sickle Cell Disease (HBB) Spinal Muscular Atrophy (SMN1) Tay-Sachs Disease (HEXA) Usher Syndrome Type IF (PCDH15) Usher Syndrome Type III (CLRN1) ; normal complete blood count (exon 7 deletion not detected) Physical Attributes 5'09" ( cm) Hair Loss: ne 155 lbs (70 kg) Hair Type: Straight Eye Color: Brown, Light Brown, Freckles: Hair Texture: Fine Skin Tone: Information : Excellent te: The medical and social history was provided by the donor and cannot be verified for accuracy. Xytex Donor Profile 5227 Page 3 of 9
4 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 4 of 9 Skills Hobbies and Interest: Field Hockey, Financial Analysis Personality and Interest Attributes Education In School: In School Major: Marketing Post Graduate: Training Type: This donor holds a post graduate degree. College Degrees: Bachelor of Science, Masters, Ph.D. Immediate Medical History Brother : Brown, Dark Hair Texture: Right 1982 Age At Hair Loss: : 5' 08'' ( cm) 165 lbs. (74 kg) Occupation: Minister Body Hair: Wavy Education: Masters Eye Color: Brown Loves reading and dogs. Father : Black Hair Texture: Right Xytex Donor Profile 5227 Page 4 of 9
5 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 5 of Age At Hair Loss: : 5' 10'' ( cm) 165 lbs. (74 kg) Moderate Balding Occupation: Engineer Body Hair: Straight Education: Masters Eye Color: Brown Enjoys computers and electrical projects Mother : Brown, Light Hair Texture: Right 1959 Age At Hair Loss: : 5' 03'' ( cm) 140 lbs. (63 kg) Occupation: Math Teacher Body Hair: Wavy Education: Masters Eye Color: Brown Enjoys reading and gardening Aunt Paternal Medical History : Hair Texture: 1949 Age At Xytex Donor Profile 5227 Page 5 of 9
6 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 6 of 9 Occupation: Body Hair: Education: Eye Color: Aunt : Hair Texture: 1950 Age At Occupation: Body Hair: Education: Eye Color: Aunt : Hair Texture: 1952 Age At Occupation: Body Hair: Education: Eye Color: Grandfather : Poor Xytex Donor Profile 5227 Page 6 of 9
7 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 7 of 9 Brown, Dark Hair Texture: 1924 Age At 5' 09'' ( cm) 160 lbs. (72 kg) Condition: Cataracts On Set Age: 80 Occupation: Manager Body Hair: Right Education: College Eye Color: Brown Enjoys volunteering and reading Condition: (Glaucoma) On Set Age: 80 Grandmother : Blonde, Light Hair Texture: Fair Fair Deceased 1929 Age At 87 5' 04'' ( cm) 150 lbs. (68 kg) Occupation: Old Age Homemaker/volunteer Body Hair: Right Education: College Eye Color: Blue Enjoyed volunteering and reading Condition: Osteoarthritis On Set Age: 60 Xytex Donor Profile 5227 Page 7 of 9
8 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 8 of 9 Condition: Stroke On Set Age: 80 Uncle : Hair Texture: 1953 Age At Occupation: Body Hair: Education: Eye Color: Maternal Medical History Grandfather : Brown, Light Hair Texture: Thin Right Fair 1935 Age At : 5' 07'' ( cm) 170 lbs. (77 kg) Enjoys gardening Occupation: Brick Layer Body Hair: Education: High School Eye Color: Brown Condition: GI (Ulcerative Colitis) On Set Age: 73 Large Grandmother : Xytex Donor Profile 5227 Page 8 of 9
9 Xytex Donor Profile 5227 Basic Version as of Tuesday September 20, 2016 Page 9 of 9 Blonde, Lightest Freckles: Few Skin Tone: Fair Hair Texture: Right 1936 Age At : 5' 02'' ( cm) 130 lbs. (59 kg) Enjoys reading Uncle Occupation: Housekeeper Body Hair: Wavy Education: High School Eye Color: Blue : Hair Texture: 1962 Age At Occupation: Body Hair: Education: Eye Color: : Xytex Donor Profile 5227 Page 9 of 9
Welcome to SKOV s Extended Donor Profile
Welcome to SKOV s Extended Donor Profile SKOV voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General Information and characteristics
Carrier Screening For Genetic Diseases Preconception Consent (Female and/or Male Partner)
Carrier Screening For Genetic Diseases Preconception Consent (Female and/or Male Partner) The goal of our practice at ARMS is to make sure that you receive optimal care to improve your chances of having
Welcome to MELIK s Extended Donor Profile
Welcome to MELIK s Extended Donor Profile MELIK voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General Information and characteristics
Welcome to AEROZ s Extended Donor Profile
Welcome to AEROZ s Extended Donor Profile AEROZ voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General information and characteristics
Welcome to MIO s Extended Donor Profile
Welcome to MIO s Extended Donor Profile MIO voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General Information and characteristics
Welcome to PASCAL s Extended Donor Profile
Welcome to PASCAL s Extended Donor Profile PASCAL voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General information and characteristics
Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD
Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD Responsible Party Telephone Number Date Name of Child Date of Birth Time of Birth Sex Resident County Placement County
Optional Tests Offered Before and During Pregnancy
Plano Women s Healthcare Optional Tests Offered Before and During Pregnancy Alpha-Fetoprotein Test (AFP) and Quad Screen These are screening tests that can assess your baby s risk of having such birth
A Guide to Prenatal Genetic Testing
Patient Education Page 29 A Guide to Prenatal Genetic Testing This section describes prenatal tests that give information about your baby s health. It is your choice whether or not to have these tests
Genetic Mutations. Indicator 4.8: Compare the consequences of mutations in body cells with those in gametes.
Genetic Mutations Indicator 4.8: Compare the consequences of mutations in body cells with those in gametes. Agenda Warm UP: What is a mutation? Body cell? Gamete? Notes on Mutations Karyotype Web Activity
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com
Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous www.retinasanantonio. com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) 615-1311 Moises A. Chica, MD San Antonio,
Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD
Responsible Party Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD Birth Name of Child Telephone Number Date Date of Birth of Child Time of Birth Sex Resident County
FAMILY CONTACT INFORMATION
FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please
Marrying a relative. Is there an increased chance that a child will have genetic problems if its parents are related to each other?
Marrying a relative Is there an increased chance that a child will have genetic problems if its parents are related to each other? The simple answer to this question is Yes, there is an increased chance.
Patient Information. for Childhood
Patient Information Genetic Testing for Childhood Hearing Loss Introduction This document describes the most common genetic cause of childhood hearing loss and explains the role of genetic testing. Childhood
Welcome to SPINO s Extended Donor Profile
Welcome to SPINO s Extended Donor Profile SPINO voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General Information and characteristics
Genetic Testing in Research & Healthcare
We Innovate Healthcare Genetic Testing in Research & Healthcare We Innovate Healthcare Genetic Testing in Research and Healthcare Human genetic testing is a growing science. It is used to study genes
This fact sheet describes how genes affect our health when they follow a well understood pattern of genetic inheritance known as autosomal recessive.
11111 This fact sheet describes how genes affect our health when they follow a well understood pattern of genetic inheritance known as autosomal recessive. In summary Genes contain the instructions for
CRYOBANK.com June / Q2-2015
FAMILY BEGINS TRUST THE NEXT STEP TO CALIFORNIA CRYOBANK IN THE HEART CRYOBANK.com WELCOME TO CALIFORNIA CRYOBANK WELCOME TO CALIFORNIA CRYOBANK Welcome to California Cryobank! Thank you for your recent
Thank you for making a reproductive genetic counseling appointment at the Mount Sinai Medical Center.
Division of Medical Genetics Department of Genetics and Genomic Sciences Mailing address: One Gustave L. Levy Place, Box 1497 New York, NY 10029-6574 Patient Address: 1428 Madison Avenue (at 99th Street)
Baby Lab. Class Copy. Introduction
Class Copy Baby Lab Introduction The traits on the following pages are believed to be inherited in the explained manner. Most of the traits, however, in this activity were created to illustrate how human
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
This application is to obtain a Birth Certificate for individuals who were born in Ontario. Applicant Information
This application is to obtain a Birth Certificate for individuals who were born in Ontario. Please type in the information for this application on your computer, print it out and sign it. Alternatively,
Variations on a Human Face Lab
Variations on a Human Face Lab Introduction: Have you ever wondered why everybody has a different appearance even if they are closely related? It is because of the large variety or characteristics that
Releasing Original Illinois Birth Certificates
Releasing Original Illinois Birth Certificates Illinois law (750 ILCS 50/18.04) provides for the release of original birth certificates to adopted and to surrendered persons 21 years of age or older upon
Known Donor Questionnaire
Known Donor Questionnaire Your donor s answers to these questions will provide you with a wealth of information about his health. You ll probably need assistance from a health care provider to interpret
PRACTICE PROBLEMS - PEDIGREES AND PROBABILITIES
PRACTICE PROBLEMS - PEDIGREES AND PROBABILITIES 1. Margaret has just learned that she has adult polycystic kidney disease. Her mother also has the disease, as did her maternal grandfather and his younger
Simon Scholar Application Class of 2018
Simon Scholar Application Class of 2018 Please attach your photo here STUDENT INFORMATION (Note: Please complete application in black ink only DO NOT USE A PENCIL) Name: First MI Last Last 4 digits of
Welcome to DARIN s Extended Donor Profile
Welcome to DARIN s Extended Donor Profile DARIN voluntarily provided the following information which will be disclosed to future parents as an aid in their selection General Information and characteristics
UNIT 13 (OPTION) Genetic Abnormalities
Unit 13 Genetic Abnormailities 1 UNIT 13 (OPTION) Genetic Abnormalities Originally developed by: Hildur Helgedottir RN, MN Revised (2000) by: Marlene Reimer RN, PhD, CCN (C) Associate Professor Faculty
Midha Medical Clinic REGISTRATION FORM
Midha Medical Clinic REGISTRATION FORM Today s / / (PLEASE PRINT NEATLY) PATIENT INFORMATION Last Name: First Name: Middle Initial: IS THIS YOUR LEGAL NAME? YES NO IF NOT, WHAT IS YOUR LEGAL NAME DATE
Each person normally has 23 pairs of chromosomes, or 46 in all. We inherit one chromosome per pair from our mother and one from our father.
AP Psychology 2.2 Behavioral Genetics Article Chromosomal Abnormalities About 1 in 150 babies is born with a chromosomal abnormality (1, 2). These are caused by errors in the number or structure of chromosomes.
New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
Medical Matters Action Checklists
Medical Matters Action Checklists The following Action Checklists are included in Chapter 5: Medical History Personal Medication Record Health Care Power of Attorney Medical Orders (Do Not Resuscitate/POLST)
Influences on Birth Defects
Influences on Birth Defects FACTS About 150,000 babies are born each year with birth defects. The parents of one out of every 28 babies receive the frightening news that their baby has a birth defect There
Florida Neurology, P.A.
Florida Neurology, P.A. Sam Shanmugham, MD Elias Gizaw, MD Nitesh Shekhadia, MD Ramit Panara, MD Robert Rahe, PA-C Lake Mary Orange City Tavares 755 Stirling Center Place Lake Mary, FL 32746 (407) 333-1718
Personal Contact and Insurance Information
Kenneth A. Holt, M.D. 3320 Executive Drive Tele: 919-877-1100 Building E, Suite 222 Fax: 919-877-8118 Raleigh, NC 27609 Personal Contact and Insurance Information Please fill out this form as completely
Not All Stem Cells are the Same
Cord Blood Banking and Transplantation Jennifer Willert, M.D. Hematology/Oncology Blood and Marrow Transplant Rady Children s Hospital San Diego Clinical Professor UCSD Not All Stem Cells are the Same
BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES
BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form Front Office Person calls in for a new patient appointment. o Never seen at SWAN o Previously Seen at SWAN The following
Genetics Review for USMLE (Part 2)
Single Gene Disorders Genetics Review for USMLE (Part 2) Some Definitions Alleles variants of a given DNA sequence at a particular location (locus) in the genome. Often used more narrowly to describe alternative
2013 ENVIRONMENTAL LITIGATION GROUP (ELG) SCHOLARSHIP POLICIES SUBMISSION DEADLINE: MARCH 1, 2013
2013 ENVIRONMENTAL LITIGATION GROUP (ELG) SCHOLARSHIP POLICIES SUBMISSION DEADLINE: MARCH 1, 2013 1. ACADEMIC QUALIFICATIONS: It is expected that applicants in high school will have a 3.5 grade point average
Mitosis, Meiosis and Fertilization 1
Mitosis, Meiosis and Fertilization 1 I. Introduction When you fall and scrape the skin off your hands or knees, how does your body make new skin cells to replace the skin cells that were scraped off? How
Name: 4. A typical phenotypic ratio for a dihybrid cross is a) 9:1 b) 3:4 c) 9:3:3:1 d) 1:2:1:2:1 e) 6:3:3:6
Name: Multiple-choice section Choose the answer which best completes each of the following statements or answers the following questions and so make your tutor happy! 1. Which of the following conclusions
Junior s Family Tree Inherited Traits of Animals
Junior s Family Tree Inherited Traits of Animals Objectives 1. Students will understand genetic make-up is received from both parents and is expressed by traits that can be predicted. 2. Students will
Underwriting Practices
Chapter 3 Underwriting Practices An underwriter s objective is to know as much cants. A majority of BC/BS plans (20 of 25) about the applicant s health status as the applicant. represented by an underwriter
Potomac Valley Chiropractic Personal Injury
Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------
Heredity. Sarah crosses a homozygous white flower and a homozygous purple flower. The cross results in all purple flowers.
Heredity 1. Sarah is doing an experiment on pea plants. She is studying the color of the pea plants. Sarah has noticed that many pea plants have purple flowers and many have white flowers. Sarah crosses
ALBINISM. Other Common Names. Causes/Etiology. Incidence. Characteristics. Hypopigmentation
ALBINISM Other Common Names Hypopigmentation Causes/Etiology Incidence Most types of albinism are inherited when a child receives the albinism gene from both parents. There is an exception with one type
If there are any questions, please feel free to contact us directly. We will do our best to make your home study experience as positive as possible.
Dear Home Study Applicant, Thank you for considering Adoption Makes Family as the agency to conduct your home study. We consider it a privilege to help families through the adoption process. Adoption is
Stem Cell Transplantation and the Canadian First Nations Community. Becky Luk (PTLS) Tanya Petraszko, MD
Stem Cell Transplantation and the Canadian First Nations Community Becky Luk (PTLS) Tanya Petraszko, MD Why is there a need for stem cells? Our Story Why are we engaging the First Nations, Metis and Inuit
Genetics with a Smile
Teacher Notes Materials Needed: Two coins (penny, poker chip, etc.) per student - One marked F for female and one marked M for male Copies of student worksheets - Genetics with a Smile, Smiley Face Traits,
Obstetrical Ultrasound and Prenatal Diagnostic Center
Obstetrical Ultrasound and Prenatal Diagnostic Center Prenatal Diagnosis: Options and Opportunities Learn about various screening options including Early Risk Assessment (ERA), now available to women of
CRYOPRESERVATION FACILITIES/STORAGE BANKS
Chapter Eight CRYOPRESERVATION FACILITIES/STORAGE BANKS The concept of storing human tissue for future use by either the donor or an anonymous person is a concept that arose during the last half of the
Hardy-Weinberg Equilibrium Problems
Hardy-Weinberg Equilibrium Problems 1. The frequency of two alleles in a gene pool is 0.19 (A) and 0.81(a). Assume that the population is in Hardy-Weinberg equilibrium. (a) Calculate the percentage of
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
A Guide to Family Health History
1 Does it Run in the Family? A Guide to Family Health History genetic alliance Contents This toolkit will help you collect, organize, and understand your family health history. In Book 1: A Guide to Family
First Trimester Screening for Down Syndrome
First Trimester Screening for Down Syndrome What is first trimester risk assessment for Down syndrome? First trimester screening for Down syndrome, also known as nuchal translucency screening, is a test
Trinity School of Durham and Chapel Hill
Trinity School of Durham and Chapel Hill Application Requirements 7 12 Grades 7 8 Application Copy of Birth Certificate Applicant Questionnaire One (1) English Teacher Reference One (1) Math Teacher Reference
Preimplantation Genetic Diagnosis. Evaluation for single gene disorders
Preimplantation Genetic Diagnosis Evaluation for single gene disorders What is Preimplantation Genetic Diagnosis? Preimplantation genetic diagnosis or PGD is a technology that allows genetic testing of
A trait is a variation of a particular character (e.g. color, height). Traits are passed from parents to offspring through genes.
1 Biology Chapter 10 Study Guide Trait A trait is a variation of a particular character (e.g. color, height). Traits are passed from parents to offspring through genes. Genes Genes are located on chromosomes
GENETIC CONSIDERATIONS IN CANCER TREATMENT AND SURVIVORSHIP
GENETIC CONSIDERATIONS IN CANCER TREATMENT AND SURVIVORSHIP WHO IS AT HIGH RISK OF HEREDITARY CANCER? Hereditary Cancer accounts for a small proportion of all cancer or approximately 5-10% THE DEVELOPMENT
1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840
Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible
Cystic Fibrosis. Cystic fibrosis affects various systems in children and young adults, including the following:
Cystic Fibrosis What is cystic fibrosis? Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the glands that produce sweat and mucus. It is chronic, progressive, and is usually
Health Information Form for Adults
A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home
A GUIDE TO WRITING YOUR LIFE STORY. Identifying information: Name and maiden name, date and place of birth:
1 A GUIDE TO WRITING YOUR LIFE STORY You are welcome to answer the following questions here or write your own essay on separate paper. If you would like to complete this on your computer ask your trainer
Consultation with Ultrasound Consultation Only Fetal Non-Stress Test BPP Nuchal Translucency Routine Ultrasound Only Amniocentesis
Appointment Information: Desired Appointment Type: (Check all that apply) Consultation with Ultrasound Consultation Only Fetal Non-Stress Test BPP Nuchal Translucency Routine Ultrasound Only Amniocentesis
Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible.
PAUL L. TREGER, M.D. RANDALL CONRAD, O.D. GLENN B. COOK, M.D., PhD TARA BROWN, M.D. 7877 PARKWAY DRIVE SUITE 100 - LA MESA, CA 91942 619.286.3711 FAX 619.286.2184 Dear Please allow us to welcome you to
Health Information Form for Adults
A. IDENTIFICATION B. EMERGENCY CONTACTS Name (Last) (First) (Middle) Maiden Name Primary Alternate In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Relationship Home Work Home
Corporate Medical Policy Carrier Testing for Genetic Disease
Corporate Medical Policy Carrier Testing for Genetic Disease File Name: Origination: Last CAP Review: Next CAP Review: Last Review: carrier_testing_for_genetic_disease 12/2013 8/2015 8/2016 8/2015 Description
APPENDIX B SAMPLE INFORMED CONSENT FORM
APPENDIX B SAMPLE INFORMED CONSENT FORM B.1 INFORMED CONSENT TO PARTICIPATE IN A RESEARCH STUDY Umbilical Cord Blood Banking for Transplantation You are being asked to take part in a research study that
Medical Questionnaire and Informed Consent Public Cord Blood Bank Switzerland
Medical Questionnaire and Informed Consent Public Cord Blood Bank Switzerland You have just read the information sheet for cord blood donors and you would like to donate cord blood. We thank you for answering
Finding A Cure to Diabetes Through Animal-Based Research
Finding A Cure to Diabetes Through Animal-Based Research Janay Johnson Life Science Team Introduction Animal based research has contributed to numerous medical advances for humans. Despite scientific advances,
Application Form. Global Green MBA
Faculty of Management The International School Application Form Global Green MBA Instructions All of the following materials must be submitted before your application will be processed: Application Form
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
Dear Prospective Preschool Family,
375A Benfield Road Severna Park, MD 21146 410-647-7055 410-647-7411 Fax Dear Prospective Preschool Family, Thank you for your interest in St. Martin s-in-the-field Episcopal School. We welcome you to our
DNA Determines Your Appearance!
DNA Determines Your Appearance! Summary DNA contains all the information needed to build your body. Did you know that your DNA determines things such as your eye color, hair color, height, and even the
Occupational Medicine
2408 Wanda Daley Drive Ames, Iowa 50011-3602 (515) 294-5359 www.ehs.iastate.edu Copyright Reviewed 2015 Environmental Health and Safety 2809 Daley Drive Ames, IA 50011-3660 Ph: (515) 294-5359 www.ehs.iastate.edu
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
EMPLOYMENT APPLICATION
EMPLOYMENT APPLICATION P.O. Box 7 Amsterdam, NY 12010 518-842-2410 800-836-7877 Fax: 888-842-1207 Hill & Markes, Inc. supports equal opportunity for all employment candidates, as well as existing associates,
All About Human Hair and Hair Loss. 1. Story
All About Human Hair and Hair Loss 1. Story Hair has always been an important sign of beauty. This is especially true for women. Next to the face, hair is one of the main qualities people look for when
Student Scholarship Application
Student Scholarship Application Take Stock in Children scholarship recipients receive: A Scholarship A full-tuition Florida Prepaid College Scholarship, which can be used at any public university, college,
Rhesus Negative 10:Rhesus Negative July 06. rhesus negative. what it means
Rhesus Negative 10:Rhesus Negative July 06 14/04/2010 rhesus negative what it means This leaflet contains important information which may affect your pregnancy. Please read it very carefully. 16:15 P When
CORONADO EYE ASSOCIATES GLENN B. COOK, M.D., PhD 801 ORANGE AVENUE, STE. 204 - CORONADO, CA 92118 619.437-4406 FAX 619.522-7983
Dear Please allow us to welcome you to our practice. Our first priority is to provide you with the best care possible. Enclosed is your patient information sheet and medical history questionnaire. Please
INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
Heredity - Patterns of Inheritance
Heredity - Patterns of Inheritance Genes and Alleles A. Genes 1. A sequence of nucleotides that codes for a special functional product a. Transfer RNA b. Enzyme c. Structural protein d. Pigments 2. Genes
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your
LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION
A-02 form.patient.demographic.information Rev. (01/14) DATE: SIGNATURE: PHYSICIAN (PLEASE PRINT) LITTLE ELM MEDICAL CLINIC S PATIENT DEMOGRAPHIC INFORMATION PATIENT'S FULL NAME ADDRESS APT. # CITY STATE
Please bring the following with you to your appointment: Completed New Patient forms A list of all prescribed medications with dosages and quantity
Mark E. Hollingshead, M.D. Cataract & Refractive Surgeon Welcome: We look forward to being of assistance to you on your first visit with Hollingshead Eye Center. In order to provide the best possible service,