Lab Referral: Notify the IVF Lab of an Upcoming Case

The Lab Referral form is used to notify the lab of the case and to provide instructions regarding the ART procedures to perform.  The lab referral can only be filled out by the clinic.  It can be printed by the lab, but is read only and cannot be edited by the lab.

Viewing the Lab Referral

The lab referral can be accessed within the cycle by clicking on the lab referral tab.  

1. Digitally Signed By- The name, date and time of the physician that digitally signed the lab referral will appear here.  If there is no digital signature present, this means that the physician has not digitally signed the lab referral.

2. Physician- The physician selected in the cycle will show here.

3. Patient, Partner Address- The patient and partner name, date of birth and sex will appear here as well as the chart ID and address of the patient.

4. Overview/Summary of Patient’s Care Request- The information here includes the setup date, date of procedure, time of procedure, provider and location.

The lab referral can be printed by clicking on the printer icon in the top right corner of the lab referral.  Use the scroll bar on the right side of the screen to scroll through and view the items on the lab referral.

1. Primary ART Procedures- The primary ART procedures selected by the clinic will be listed here.  In the example, IVF, ICSI and PGT were selected.  

2. Genetic Material- The origin of the sperm and egg will be listed here as well as whether it is a fresh or frozen sperm, eggs or a frozen embryo (when applicable).  The partner’s semen analysis will pull in here (if applicable) and the clinic will indicate the Ovum Donor or Sperm Donor number if that applies to the patient’s cycle.

3. Laboratory Procedures- The lab procedures selected by the clinic will populate here as well as the proportion of oocytes to ICSI and any additional notes.

4. Preimplantation Genetic Testing- If PGT is requested, that will be indicated as well as the name of the PGT laboratory, biopsy days, additional notes made by the clinic, type of PGT testing and if there is a desired gender/patient does not want to know the gender.

1. Embryo Transfer- Will the patient have a fresh embryo transfer: Yes or No.  If yes, the clinic will indicate the anticipated number of embryos to transfer.  Will there be a transfer to a gestational surrogate: Yes or No.  If yes, the clinic will list the surrogate name.

2. Cryopreservation- What will be frozen and at which stage will be listed here as well as any special instructions.  

3. Frozen Embryo Transfer- Will the patient be having a frozen embryo transfer in this cycle: Yes or No.  If yes, the clinic will include the anticipated number to transfer, thaw date, FET date and any special instructions.

4. FDA Eligibility- Donated oocyte, semen or embryos eligibility status, date of eligibility determination and any waivers or notes will be listed here when applicable.

5. Patient History/Prior ART Cycles- The clinic will indicate here if the patient has been treated in the lab previously, if the patient/couple have previously conceived and any comments.

6. Reason for ICSI- The reason for ICSI is listed here. 

7. Indication for PGT- If PGT is applicable, the indication(s) for PGT will be listed here.

8. Indication for ART- The indication for ART will be listed here.

The authorizing physician and date will be listed at the bottom of the referral.

***All manuals are compliant with HIPAA regulations.  No patient information has been released.  All screenshots above were taken from a test clinic with fake patient information.