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Maternal Fetal Center / Prenatal Diagnostic CenterPhysician Referral Form Fax: (559) 3536710 Email: Referral ValleyChildrens.org PATIENT INFORMATION Name (Last / First / MI):DOB:Address:Zip:Phone:
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How to fill out maternal-fetal-center-referral-form
How to fill out maternal-fetal-center-referral-form
01
To fill out the maternal-fetal-center-referral-form, follow these steps:
02
Obtain a copy of the referral form either online or from the maternal-fetal center.
03
Read the instructions provided on the form carefully.
04
Fill in your personal information such as name, contact details, and date of birth.
05
Provide relevant medical history, including any previous pregnancies or medical conditions.
06
Specify the reason for the referral and any specific concerns or symptoms.
07
If applicable, provide details of the referring healthcare provider.
08
Attach any supporting documents or test results that may be required.
09
Review the filled form for accuracy and completeness.
10
Submit the completed form to the maternal-fetal center through the designated method (e.g., mail, fax, online portal).
Who needs maternal-fetal-center-referral-form?
01
The maternal-fetal-center-referral-form is needed by individuals who require specialized care or consultation during pregnancy.
02
These individuals may include:
03
- Pregnant women with high-risk conditions, such as gestational diabetes or preeclampsia.
04
- Women with a history of pregnancy complications or fetal abnormalities.
05
- Patients with underlying medical conditions that may impact pregnancy outcomes.
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- Women expecting multiple pregnancies (twins, triplets, etc.).
07
- Individuals with fetal growth concerns or suspected genetic disorders.
08
It is advisable for healthcare providers, such as obstetricians, midwives, or family doctors, to complete and submit the referral form on behalf of their patients to ensure appropriate care and coordination.
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What is maternal-fetal-center-referral-form?
The maternal-fetal-center-referral-form is a form used to refer patients to a specialized center for high-risk pregnancies.
Who is required to file maternal-fetal-center-referral-form?
Healthcare providers, obstetricians, or specialists involved in the care of pregnant women with high-risk conditions are required to file the maternal-fetal-center-referral-form.
How to fill out maternal-fetal-center-referral-form?
The form can be filled out by providing detailed information about the patient's medical history, current condition, and the reason for referral to the maternal-fetal center.
What is the purpose of maternal-fetal-center-referral-form?
The purpose of the maternal-fetal-center-referral-form is to ensure that pregnant women with high-risk conditions receive specialized care and treatment at a designated center.
What information must be reported on maternal-fetal-center-referral-form?
The form must include the patient's demographic information, medical history, current pregnancy details, reasons for referral, and any relevant test results.
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