GG Peaches&Me Questionnaire

1
Alright, so what's your name?* This field is required.
First Name
Middle Name
Last Name
2
Thanks, {Name}! Can I now have your date of birth please?* This field is required.
Date
Month
Day
Year
3
Please provide your email address:* This field is required.
example@example.com
4
Thanks for that. What's your mobile phone number?* This field is required.
Please enter a valid phone number.
5
Appreciate that... Now, we need to get your shipping address please:* This field is required.This is where your kit will be shipped.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Great! What was your assigned sex at birth?* This field is required.
Female
Male
Other
7
Thank you. What's your ethnicity?If you choose not to answer this question, you may just click 'NEXT'.
African American
Ashkenazi Jewish
East Asian (China, Japan, Korea)
Finnish
French Canadian
Hispanic American
Mennonite
Middle Eastern (Saudi Arabia, Qatar, Iran, Iraq, Turkey)
Native American
Northern European Caucasian (Scandinavian, UK, Germany)
Pacific Islander (Philippines, Micronesia, Malaysia, Indonesia)
South Asian (India, Pakistan)
Southeast Asian (Vietnam, Cambodia, Thailand)
Southern European (Spain, Italy, Greece)
Other
8
Ok, next question: has there already been an ultrasound done confirming the viability of your pregnancy?* This field is required.
YESNO
9
If you know the date of your ultrasound, enter it below:If you don't remember or can't find it now, you may click 'NEXT'.
Date
Month
Day
Year
10
What's your estimated due date?* This field is required.Knowing your estimated due date is a requirement for proceeding with this process.
Date
Month
Day
Year
11
Nice! How was your due date determined?* This field is required.
By ultrasound
Based on my last menstrual period
I don't know how it was determined
12
I see. Are your menstrual periods regular?* This field is required.
YESNO
13
Got it. If you know the date of the first day of your last menstrual period, enter it below:If you don't know it, just click 'NEXT'.
Date
Month
Day
Year
14
Ok, so this screening also predicts the sex of the baby. How would you like us to inform you of that result?* This field is required.
I don't want me or anyone else to know the sex until the baby is born
I want the result revealed to me and the intended parents once available
I want the result to only be revealed to a third party (please pick this option if the intended parents would like to keep the sex of the baby a secret and would only want a third-party to know it instead of themselves.)
15
Exciting! We just need to make sure we have legal consent. Please read below. If you do not agree, you may click on 'PREVIOUS' and change your answer.* This field is required.
I give full consent to Mitera to reveal the predicted sex of the baby to a third-party that I identify during this intake process. However, if any of my results are abnormal or indeterminate, Mitera will not reach out to the third-party and will contact me and the intended parents with the results instead.
16
Alright, so who is this person? * This field is required.Please make sure they are expecting to hear from Mitera.
Full Name
Relationship (sister, friend, baker, etc.)
Phone Number
Email Address
Date of Birth
17
Great. We have some more questions for you. Is this an IVF pregnancy?* This field is required.If you are a surrogate, the answer would be YES.
YESNO
18
How many embryos were transferred?* This field is required.
19
Was ovum (egg) donation used?* This field is required.
YESNO
20
What was the age of the egg donor at the time of donation?If you don't know the answer, just click on 'NEXT'.
21
Are you carrying this pregnancy as a gestational carrier (surrogate)?* This field is required.
YESNO
22
Got it. How many fetus(es) with this pregnancy?* This field is required.
Singleton
Twins
Triplets
More than 3
I don't know
23
Have you had any previous pregnancies?* This field is required.
YESNO
24
How many?* This field is required.List only previous and not a current pregnancy.
25
Did your previous pregnanci(es) have any complications?* This field is required.Choose all that apply.
No complications
Low birth weight
Preeclampsia
Gestational diabetes
Fetal growth restriction
Preterm delivery
Birth defect
Genetic abnormality
Other
26
Did all your previous pregnanci(es) end in delivery?* This field is required.
YESNO
27
Please explain:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
28
Thanks for all of that information. Besides the intended parents, is there an OB GYN or another medical provider that we should send the results sent to?* This field is required.
YESNO
29
What is the doctor's name?* This field is required.
Dr.
Dr.
Other
First Name
Last Name
30
What's the doctor's phone number?* This field is required.
Please enter a valid phone number.
31
What's the clinic's fax number? This would be very helpful for us to make sure they get your results. But if you don't know it, just press 'Next'.
Please enter a valid phone number.
32
What's the clinic's email address? This would be helpful as well. But if you don't know it, just press 'Next'.
example@example.com
33
Now, please check off any of the following statements if it applies to you (Check all that apply):* This field is required.:
I am 35 or older
I have a family or personal history of a prior pregnancy affected by birth defects or genetic abnormality
I had an abnormal result on a serum screening for this pregnancy
None of the above applies to me
34
Please explain your answer(s) to the previous question: * This field is required.If you have had an abnormal screening result or have a personal or family history of birth defects or genetic abnormalities, please provide details below.
Huge
Large
Normal
Small
Ok
Ok
35
Ok. Thanks for your patience! We won't be too much longer. For the next part, I’ll be asking you some general health-related questions: First, do you have any medical conditions? * This field is required.
YESNO
36
What condition(s)?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
37
Do you take any medication(s)?* This field is required.
YESNO
38
Please list the medication(s) you're taking:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
39
Ok, so how tall are you?* This field is required.
3’0”
3’1”
3’2”
3’3”
3’4”
3’5”
3’6”
3’7”
3’8”
3’9”
3’10”
3’11”
4’0”
4’1”
4’2”
4’3”
4’4”
4’5”
4’6”
4’7”
4’8”
4’9”
4’10”
4’11”
5’0”
5’1”
5’2”
5’3”
5’4”
5’5”
5’6”
5’7”
5’8”
5’9”
5’10”
5’11”
6’0”
6’1”
6’2”
6’3”
6’4”
6’5”
6’6”
6’7”
6’8”
6’9”
6’10”
6’11”
7’0”
7’1”
7’2”
40
What is your weight?* This field is required.In lbs.
41
Thank you! By the way, how did you hear about us?* This field is required.
Google
The Knot
The Bump
Instagram
TikTok
Facebook
My doctor
My friend
Growing Generations
Other
42
Awesome! Thanks so much for powering through! Really... We know it can get tiring. We're almost there. We promise! Now, we need you to watch a quick video to learn more about your screening and how it can empower you with information regarding your reproductive journey. Please remember that if you don't complete the entire process, your order will not be submitted and you will have to start the process over again.* This field is required.Instead of watching the video, you may consult a genetic counselor at Mitera about the test at no additional cost. You may email hello@miteragenetics.com to request your pre-test appointment. You will be seen by a genetic counselor within 72 hours.
I understand. I prefer to watch the video and complete the process at this time.
Instead of watching a video, I would like to consult a genetic counselor. I do understand that it may take up to 72 business hours to see a genetic counselor. Once my appointment is complete, and I decide to move forward, this test order will be processed.
43
Please turn up the volume and watch this ENTIRE educational video about your NIPT screening. You must attest to having watched an d understood the entire video before completing this questionnaire.
44
After having watched the video and understood the pros, cons and limitations of NIPT, would you still like to complete this order?* This field is required.If you click on 'NO' your order will not be processed.
YESNO
45
Informed Consent for {Name}:* This field is required.I understand that a pre-test consultation with a genetic counselor was available to me at no additional cost to provide me with adequate information for deciding whether or not to move forward with non-invasive prenatal screening. If I declined to speak to a genetic counselor prior to completing my test request process, Mitera's educational video provided the information I needed and it answered all of my questions. I watched the educational video about Non-Invasive Prenatal Testing (NIPT) in its entirety, fully understood it and I am now aware of the test's risks and limitations. I further give full consent to proceed with the screening process. The virtual Mitera medical visit is now fully complete. The information I have provided will be fully reviewed by a licensed provider. If appropriate, he or she will place an order for the requested test. If not, the test will not be ordered. I will be notified in either case. I understand that upon the approval of my request, I will be sent an at-home kit and it is my responsibility to follow instructions and submit the sample promptly. Mitera is a telehealth service provider and not a laboratory. The test I have ordered through Mitera is administered and processed by a third-party laboratory, NxGen MDx ("laboratory"). In addition to Mitera’s Terms of Use, I am required to consent to NxGen MDx's terms and conditions (which are listed below) to proceed with the testing process. Mitera is not responsible for any errors made in the administration and processing of these tests and solely provides the medical and logistical services to facilitate the testing. I understand that the NxGen Informed Prenatal Test (NIPT) only determines my child’s risk for Down syndrome, Edwards syndrome, and Patau syndrome. It also screens for sex chromosome aneuploidies and fetal sex. A positive NIPT result only indicates that my pregnancy is at risk for trisomy 13, 18, 21, or a sex chromosome aneuploidy. It is not a definitive result. With this result, diagnostic testing and genetic counseling are recommended for a more definitive diagnosis, since this is only a screening test and not a diagnostic one. I understand that false positives and false negatives do occur for a certain percentage of these tests. I also understand that a false result may occur when determining my baby’s sex. As such, I hold both Mitera and NxGen MDx harmless in case of false results. I further understand that I will be provided genetic counseling if I receive a positive result of any kind. This process also involves a third-party mobile phlebotomy company, Workpath. By accepting to move forward, I understand that I will have to accept Workpath’s terms of use. I will hold Mitera and NxGen MDx harmless in case of any wrongdoing or negligence by Workpath’s employees or contractors. I authorize the NxGen MDx laboratory to provide my health plan with the information on this form and other information provided by my healthcare provider if necessary for reimbursement. I understand that the laboratory may seek prior authorization for testing from my health plan on my behalf. I also authorize all benefits from the plan to be payable directly to the laboratory, and I agree to remit to the laboratory any payment for these services made directly to me. I understand that the laboratory may be an out-of-network provider for my health plan and that I am responsible for all amounts not reimbursed by my health plan. I hereby designate the laboratory as my Authorized Representative, as provided under ERISA, 29 C.F.R § 2560.5031 (b)(4), and/or as my Attorney in Fact, for the purpose of pursuing administrative appeals to which I am entitled and, if the laboratory deems it appropriate, any legal and/or equitable claims that I could bring against my health plan, and/or its administrators, with respect to their handling or resolution of my insurance claim. I agree that my de-identified specimen and test or other data (where information that could link me to the specimen or data has been removed, making it unlikely that I could be identified) may be retained, used and disclosed for research and/or to help develop products or services, in compliance with applicable laws. I understand that I will not receive any royalties, payments, benefits or rights from any resulting products or discoveries, and that if I do not want my de-identified specimen and test data to be retained, used, or disclosed for research or product development purposes I should call Customer Service at 1-855-776-9436. All leftover specimens from New York State will be destroyed within 60 days. SHARING OF RESULTS You provide authorization for your results to be disclosed to your ordering physician and another provider whose information you provided during the intake process. You also provide full consent to share the results of your baby’s predicted sex with another third-party whose information you have provided to Mitera. MEDICAL NECESSITY STATEMENT A medical provider has presented this test as an option to assess my reproductive risk for certain disorders. The results of this test may impact my medical care and the availability of reproductive options. The person listed as the Ordering Physician is authorized by law to order the test(s) requested herein. I confirm that I have reviewed this information with my primary care provider, and I consent to genetic testing. MITERA PRIVACY POLICY AND TERMS OF USE I have read and entirely agree with Mitera’s Privacy Policy and Terms of Use found online on the Mitera website at www.miteragenetics.com
By clicking this box, I affirm that I understand and agree with all of the statements above as well as any payment and/or insurance terms that were indicated on this intake form.
46
Signature Request - {Name}* This field is required.I affirm and certify that all the information and answers to questions I answered are complete, true and correct to the best of my knowledge and belief. I further affirm that I understand and provide consent in regards to the terms outlined in the informed consent section of this form. I understand that any misrepresentation, falsification, or omission of any facts may render this request void.
ClearSignature.
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