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Nomination of a Condition to Include in Prenatal Screening

Date

Your Name

Organization

Email Address

Phone number

Please provide the names and contact information of other individuals who wish to be included in this nomination (and their organizational/group affiliations). Indicate which individual will act as a representative for all of the nominators.

Do you or any the listed applicants have any potential financial and/or other conflicts of interest in nominating this condition for screening?

What condition do you wish to nominate and why?

What group of physicians typically provide care to patients who have this condition (i.e. obstetricians, endocrinologists, hematologists, unsure)?

Is there a test (prenatal or postnatal) for this condition and if so, what is the test?

Is there treatment available for this condition and if so, is it available in Ontario? What is the treatment?

Do you know of any other jurisdictions (in Canada or internationally), that screen for this condition prenatally or postnatally (if so, please list)?

Please provide any additional information you would like us to consider with your nomination.

Attach any relevant documents you would like us to consider (please do not upload your personal medical information).

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Nomination of a Condition to Include in Prenatal Screening

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