2315 Stockton Blvd 3rd Floor, North Wing, Office #3012
Sacramento, CA 95817
Phone: (916) 794-BABY Fax: (916) 734-4452
Email: URL: fetalcare.ucdavis.edu /
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.