Online Request for Prenatal Diagnosis/Ultrasound Service

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UNC Department of Obstetrics & Gynecology

Online Request for Prenatal Diagnosis/Ultrasound Service


 

Call (919) 843-6094 to speak with a Patient Business Associate if you have questions or need additional information.

PATIENT INFORMATION
Preferred Location  


LMP
/ /  
Working EDD
/ /  
INDICATION
Requested
SELECT SERVICE
It is important to send the following labeled with your patient’s Name and DOB: Blood Type and Screen; and if available, Serum Down Syndrome screening results, CBC, Hemoglobinopathy testing results.
FIRST TRIMESTER
SECOND OR THIRD TRIMESTER
ULTRASOUND ONLY
GENETIC COUNSELING ONLY
IMPORTANT ADDITIONAL INFORMATION
All patients with significant findings on US examinations will be provided consultation about the finding by the MFM staff, unless you specifically opt of this. In this case, we will send you the report and NOT discuss the results with the patient.
Select "Yes", if you wish to opt out of MFM consultation for this patient


If follow up US is recommended, may we schedule that or do you wish to do so separately?


REFERRING CLINICIAN INFORMATION
Preferred Method of Communication  




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