Patient Referrals for High-Risk Pregnancies - Maternity 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the patient's address and phone number. This will help facilitate communication regarding appointments.
4. Indicate the total number of pregnancies and specify if they are term, preterm, or other categories by checking the appropriate boxes.
5. Provide details about the last menstrual period (LMP) and estimated due date (EDD), selecting the basis for these dates from LMP, ultrasound, or other.
6. Complete sections on allergies, interpreter needs, earliest ultrasound date, insurance information, and type of service requested by checking relevant options.
7. In the indications section, check all applicable conditions that apply to the patient’s medical history to ensure proper care is provided.
8. Finally, have the referring provider print their name, phone number, address, fax number, sign and date the form before submission.

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