`OBSTETRIX MEDICAL GROUP of Kansas and Missouri
Office Locations:
St. Luke’s Hospital – Plaza 4323 Wornall Rd. First Floor Peet Center Kansas City, Missouri 64111
Lee’s Summit Office – Legacy Ridge Medical Building 301 NE Mulberry, Suite 202 Lee’s Summit, MO 64086
Shawnee Mission Medical Birth Center- 9100 W. 74th St. Shawnee Mission, KS 66206
For appointments at Saint Luke - Plaza Please FAX this form with records to 816-932-5137 or call 816-932-5127
For appointments at Shawnee Mission and Lee’s Summit fax this form with records to 816-525-3605 or call 816-525-2808
Date of Request:______Clinic Location: Plaza Lee’s Summit Shawnee Mission Requesting Provider:______
Patient Name:______DOB: ______Patient Phone #:______
Insurance Name: ______Insured’s Name (if different from the patient):______
Insured’s relationship to patient and DOB:______Insurance ID #:______Group #: ______
Patient email address:______
SERVICES REQUESTED(please check all that apply)
Ultrasound (consult if indicated)
□ Detailed U/S (consult performed if indicated)
□ Complete U/S
□ Limited or follow-up
□ Nuchal Translucency/ Sequential Screening
(includes Genetic Counseling + blood draws)
□ Nuchal Translucency plus Detailed U/S at 18-20 wks
□ U/S w/ Fetal Echocardiogram
(minimum 24 wks gestation)
□ Biophysical profile (includes and NST)
□ Endovaginal Ultrasound
□ AFI + Doppler
Genetic Services
□ Genetic Counseling only
□ First trimester Screening
□ Amniocentesis
□ CVS Blood type______
Physician Appointments
□ Preconception
□ Consultation Only □ Consultation w/ U/S
□ Transfer of Care
Other Services
□ Diabetes and Pregnancy Program
(Nutrition therapy, blood glucose management)
□ Amnio, fetal-lung maturity
□ Antepartum testing (please check) NST___CST__
Modified BPP ___ Diabetes Protocol_____
One time visit____ Every 3-4 days ____
Every seven days____
TO SCHEDULE BY FAX
PLEASE PROVIDE:
-Demographic sheet including patient address, best number to contact patient, Social Security #, LMP or EDC
-Insurance cards (Primary and Secondary)
-Subscriber Relationship to Patient
-Prenatal records, labs, lab copy of blood type if scheduling an amniocentesis or CVS / CLINICAL INFORMATION
Gravida:______Para:______SAB:______TAB:______
EDC:______
EDC was based on:
□ LMP______
□ Ultrasound on ______
with fetal size ______w _____d____
□ Other______
CLINICAL INDICATION FOR TODAY’S VISIT
□ Abnormal Finding on Outside U/S □ Advanced Maternal Age
□ Diabetes, Gestational
□ Diabetes, Pre-existing (Type I or II)
□ First Trimester Screening
□ History of Stillbirth
□ Hypertensive disorder
□ Incompetent Cervix
□ Large for Dates
□ Obesity, Morbid BMI______
□ Poor Fetal Growth
□ Preterm labor
□ Repetitive Miscarriage
□ Screening for malformations/chromosome abnormalities
□ Small for Dates
□ Suspected Fetal Anomaly
□ Twins □ Twin to Twin Transfusion
□ Triplets
□ Vaginal Bleeding
□ Other: (i.e., specific signs/symptoms)
______
______
Appointment Date:______
Appointment Time:______
□ INTERPRETER NEEDED
Physician Signature:______
Welcome to Obstetrix Medical Group. To learn more about our services and team, or to register online, we encourage you to visit our website at www.obstetrix.com and click on the Kansas City link.
· In order for us to provide the best possible service, we ask the following:
· Please arrive 30 minutes prior to your scheduled appointment time for registration if you are being seen at St. Luke’s on the Plaza or Shawnee Mission Medical Center. In Lee’s Summit, arrive 5-10 minutes before your appointment.
· Please bring your insurance card and ID to your appointment.
· Please be prepared to pay towards your deductible if it has not been met at the time of service or pay specialty co-pay. We accept cash, check and credit card payments
· Please turn off cell phones prior to entering the lobby.
· There are no special instructions prior to your Ultrasound or Amniocentesis.
Obstetrix does not have personnel to watch children.
We ask that you DO NOT BRING CHILDREN under the age of 10 years unless absolutely necessary.
If you bring unattended children we reserve the right to reschedule your appointment.