University of California Davis Medical Center

Fetal Care and Treatment Center (FCTC) Referral

Please fax the below information to916-734-4452. Call 916-794-BABYwith any questions.

By referring to the FCTC you will allow us to evaluate and provide comprehensive fetal evaluation as deemed

necessary by the FCTC. Additional prenatal diagnostic testing maybe ordered as clinically indicated.

Referral Indication/Fetal Anomaly: ______

Patient Name: ______DOB: ______Age: ______

LMP: ______EDD: ______G: ______P: ______

Current Gestational Age: ______Translator needed? _ No Yes - language: ______

Referring physician name: ______NPI: ______

Office phone: ______Office fax: ______

Office Address: ______

Referral coordinator name: ______

CONFIDENTIALITY NOTICE - PROTECTED UNDER EVIDENCE CODE 1157: This FAX communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, (or authorized designee for the recipient) you are hereby notified that you received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please destroy all copies of this communication and any attachments and contact the sender by telephone.

Services requested:

Fetal Ultrasound

Fetal ECHO/Cardiology

Fetal MRI

Fetal Intervention

Maternal Fetal Medicine

Prenatal Genetics

Pediatric Surgery

Transfer of obstetrical care

Specialty Service: ______

Other: ______

CONFIDENTIALITY NOTICE - PROTECTED UNDER EVIDENCE CODE 1157: This FAX communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, (or authorized designee for the recipient) you are hereby notified that you received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please destroy all copies of this communication and any attachments and contact the sender by telephone.

Please provide the following information:

Insurance information (front and back of card)

Patient Demographic Sheet

Obstetrical records from current pregnancy including:

Prenatal record with medical and pregnancy history

Ultrasound Reports

• 1st Trimester dating scan, Nuchal Translucency ultrasound, Anatomy scan, etc.

State Screening/Prenatal Screening Testing

NIPS (Harmony, Maternti 21, Panorama)

Amniocentesis/CVS results (karyotype/microarray)

Prenatal labs including Group Beta Strep (GBS) result

CONFIDENTIALITY NOTICE - PROTECTED UNDER EVIDENCE CODE 1157: This FAX communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, (or authorized designee for the recipient) you are hereby notified that you received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please destroy all copies of this communication and any attachments and contact the sender by telephone.