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Required format:

EVMS Maternal Fetal Medicine Referral Form - PHYSICIAN OFFICE USE ONLY

Returning?

A A A

Please complete the EVMS Maternal Fetal Medicine Referral Form. Ensure that all fields are completed before submitting the form.

Should you have any questions, please contact our office at 757-446-7900.

Thank you!

Date Submitted

M-D-Y

Which EVMS Office Location?

Norfolk Campus: 825 Fairfax Ave Suite 310 Norfolk, VA 23507; Phone: 757-446-7900; Fax: 757-446-7482

Princess Anne Campus: 2075 Glenn Mitchell Drive Suite 500 Virginia Beach, VA 23456; Phone: 757-689-5104; Fax: 757-689-2717

Peninsula Campus: 10852 Warwick Boulevard Newport News, VA 23601; Phone: 757-594-3636; Fax: 757-223-2958

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*Name:	*Date of Birth:	*Last 4 Digits of SSN:
*Phone:	*Email:	*Address:
*City:	*State:	*Zip Code:

*Insurance Name:	Insurance Phone Number:
Insurance Address:	Insurance City, State, Zip Code:
*Subscriber's Name:	*Relationship to Patient:
*Subscriber ID Number:	*Group Number:
Authorization Number (if required):	Plan ID (if required):

Is patient currently pregnant?

Yes

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Gravida:	Para:	*EDD:
*Dated By:	*LMP:	*First Ultrasound Date:
*First Ultrasound GA (weeks):	*First Ultrasound GA (days):	Fetal Genetic Screening:

Fetal Genetic Screening Result

Normal

Abnormal

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Please include results in uploaded records

Patient BMI

Does patient speak English?

Yes

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Preferred Language:

Translator Required:

Ultrasound Only (no anomaly suspected, no consult/discussion with MFM requested)

Dating/Viability

First trimester anatomy evaluation

Second trimester anatomy evaluation

Fetal echocardiogram

Indication for Fetal Echocardiogram

Other Indication

Antenatal Testing Only

Non-stress test

Biophysical profile

Frequency of NSTs

Indication for NSTs

Frequency of BPPs

Indication for BPPs

Fetal/Placental Concern

Suspected fetal anomaly

Suspected placental/umbilical anomaly

Suspected/Risk for fetal growth abnormality

Multiple gestation

Medications/Exposure

Other

Suspected Fetal Anomaly

Patient will be scheduled for Morphology US and Genetic consult

Suspected Placental/Umbilical Anomaly

Patient will be scheduled for Morphology US, Consult US

Patient will be scheduled for Twin US, Consult US

Medications/Exposure

Patient will be scheduled for Morphology US and Genetic consult

Other, please describe

Maternal

Gestational diabetes

Pre-gestational diabetes

Maternal medical condition

History of pregnancy complication

Preconception

Other

1 Hour GTT

3 Hour GTT (0/1hr/2hrs/3hrs)

Patient will be scheduled for Gestational diabetes class

Pregestational Diabetes Type

Type 1

Type 2

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Pregestational Diabetes Control

Diet Controlled

Medication Controlled

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HgbA1C

Patient will be scheduled for New Pregestational Diabetes Appointment, Morphology US, Fetal Echo

Maternal Medical Condition

Patient will be scheduled for MFM office consult, Morphology US

History of Pregnancy Complication

Patient will be scheduled for Morphology US and MFM Consult

Preconception Indication

Patient will be scheduled for Preconception Consultation

Other, please describe

Genetic

Abnormal fetal genetic screening

Personal/Family history of genetic/congenital disorder

Other

Patient will be scheduled for Morphology US and Genetic Consult

Personal/Family history of genetic/congenital disorder

Other, please describe

Desire Transfer of Care to EVMS

Yes

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Transfer of Care Indication

Time Frame Request

Urgent (within 7 days)

Routine (within 4 weeks)

At a specific gestational age

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Specific Gestational Age Date Range

MFM consultation and/or additional studies when indicated may be added by the MFM based on chart review and/or day of service findings.

*Referring Provider Name:	Office Phone Number:
Office Fax Number:	Contact Person:

*Please upload all applicable medical records for review (including: ultrasound reports, lab results, and office visit notes)

* must provide value

Upload file

Additional File Upload (if needed)

Upload file

Additional File Upload (if needed)

Upload file

The patient will be contacted with the date and time of their scheduled appointment.

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