The Center for Perinatal Medicine/Northside Hospital Georgia Perinatal Consultants Appointment Request fax to: 404. 845. 5155
Download 64.22 Kb.
|
- Navigate this page:
- A d dres s
- Primary I nsuranc e
- Requested
- CPM/GPC U S E O N L Y : A pp o
The Center for Perinatal Medicine/Northside Hospital Georgia Perinatal Consultants Appointment Request FAX to: 404.845.5155
Patient Name: Date of Birth:Address: City: Zip: Best # to Reach: Alternate Phone: Primary Language is other than English – please specify: Primary Insurance: Requested Procedure/Service: LMP: / /EDC: / / Early Ultrasound for dates, viability Genetic Counseling Consultation only Anatomic Assessment 1st Trimester Screening (11.6 – 13.6 weeks) Fetal Well Being / BPP CVS (11.6 – 13.6 weeks) Cervix Check / Transvaginal Ultrasound Amniocentesis ( ≥ 15 weeks) Amnio for Lung Maturity: Date of scheduled Delivery/C-Section: / / NST Injection – please indicate: Reason for Exam/Consultation: ICD-10: (MUST INCLUDE)________________________________Prior History of: miscarriage(s) pre-term labor pre-term delivery Other: Rule out anomalies Abnormal Ultrasound Finding Cervical Incompetence IUGR Confirm dates Abnormal screen result – please specify: Multiples – How many: AMA Diabetes Hypertension Other medical: Family history and/or current medications: Location Preference: None or MD Preference: None or Specific Date for patient to be seen or time frame:Requested by: Referring MD: Contact Person: Office Phone: Office Fax: --------------------------------------------------------------------------------------------------------------------------------------------------------- CPM/GPC USE ONLY: Appointment Details: Appointment Date: / / Time: Location: GPC Physician: Confirmation #: Scheduled By: Confirmed appointment date and time with patient ***Once appointment is confirmed, please fax all pertinent medical history including prenatal record, labs, etc. to the scheduled location.*** Directory: wp-content -> uploads -> 2016 2016 -> 2017 afoCo Landmark Scholarship Program 2016 -> Instructions for the Preparation of Camera-Ready Contributions to the Conference Proceedings 2016 -> Step student Scholarships for Year 10-13 2016 -> The united church of canada 2016 -> Idan raichel biography – May 2016 Brief Producer, keyboardist, Lyricist, composer and Performer Idan Raichel 2016 -> An introduction to centre’s interventions expanding access to justice 2016 -> Sanchar Shakti 2016 -> Unit analysis should help here. We want number of bananas 2016 -> The Autobiography of Elder Joseph Bates 2016 -> The Great Heat and the Rhode Island Deep Water Bay Scallop (Argopecten irradians) Fishery 1875-1905 Download 64.22 Kb. Share with your friends:
|