Provider

Referral Form

Provider

Referral Form

Please fill out the form below to request a provider referral and we’ll respond as soon as possible.

Fields marked with * are required.

Patient First Name *

Patient Last Name *

Date of Birth *

Phone *

EDD (Estimated Due Date) *

Insurance *

Group # *

ID # *

Indications/Diagnosis *

Scheduling Instructions

Schedule STAT

Schedule PRIORITY (24—48 HOURS)

Others:

Call patient to schedule: Additional Information Patient will call: Additional Information Call Report STAT: Additional Information

Obstetric Ultrasound

Singleton

Multiples:

Number of Multiples

First Trimester Viability

First Trim Nuchal Translucency

Fetal Anatomy

Follow-up/Growth:

(frequency)

Fetal Echocardiogram

Fetal Dopplers

Umbilical

MCA

Uterine Artery Doppler (Maternal)

Other:

Additional Information

Gynecologic Ultrasound

Pelvic Ultrasound

Sonohysterography

Other:

Additional Information

Antenatal Testing

BPP:

(frequency)

AFI:

(frequency)

NST:

(frequency)

Blood Tests

NIPT (Cell Free Fetal DNA)

Other:

Additional Information

Procedures

CVS (includes genetic counseling)

Amniocentesis (includes genetic counseling)

Follow-Up Testing

(as recommended/ordered by VPS)

Ultrasound

Antenatal Testing

Consults & Other Services

Maternal-fetal medicine consultation:

Maternal-fetal medicine consultation (reason)

Co-management high risk condition:

Co-management high risk condition (reason)

Genetic counseling:

Abnormal Screen

AMA

Preconception Consult

Family History

Nutritional Counseling

(celiac disease, obesity, any other non-diabetic)

Diabetes Services

Type of Diabetes

Gestational

Type I

Type II

Other:

Additional Information

Consultation Only:

30 min perinatal w/US, 90 min visit w/Registered Dietician, NP follow-up visit

Consultation w/Co-Management:

Consultation (as listed above) and ongoing diabetes co-management

Referring Physician *

Date of Request *

Referring Physician Phone *

Fax *

By submitting this referral, I am acknowledging that it is being ordered by the physician stated above. *

or call

(480) 756-6000

To learn more about how our physicians can help, contact us directly or call (480) 756-6000.

Provider

Referral Form

Provider

Referral Form

Please fill out the form below to request a provider referral and we’ll respond as soon as possible.

Scheduling Instructions

Type of Diabetes

Contact Us

You are now subscribed to the Valley Perinatal e-newsletter. Thank you!