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The document is a referral form for the Fetal Therapy Center at the University of Miami/Jackson Memorial Hospital, specifically for cases of Twin Twin Transfusion Syndrome (TTTS) and Selective Intrauterine Growth Retardation (SIUGR). It collects comprehensive patient, insurance, and physician information, along with detailed medical data related to the pregnancy and fetal conditions. The form requires submission of prenatal records, lab results, and ultrasounds.

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Versions	Form popularity	Fillable & printable
2010	4.8 Satisfied (218 Votes)

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