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University of Miami/Jackson Memorial Hospital Fetal Therapy Center Acardiac Twin Referral Form PATIENT INFORMATION , Name First SSN Address City / DOB (MM/DD/YY) Last State ZIP E-mail Employer Work Phone - - / - Phone - - Cell - - Fax - - - Employer Address Mother's Maiden Name Race Country of Birth Religion Marital Status Emergency Contact/Next of Kin Phone - Relationship Cell - - - INSURANCE INFORMATION Self Patients relationship to subscriber: Spouse Child Insurance Povider Other If other than self: Primary subscriber name? DOB (MM/DD/YY) SSN Policy # / - Group # / Insurance Phone - - - PHYSICIAN INFORMATION , Referring Perinatologist Last First Physician Address City State Phone - - Fax - - Phone - - Fax - - ZIP E-mail , Referring Ob/Gyn Last First Physician Address City State ZIP E-mail PLEASE SUBMIT BY EMAIL OR PRINT FORM AND FAX TO (305) 357-5675 PLEASE READ BEFORE SUBMISSION: If using Adobe Acrobat Pro, submit by email. If using Adobe Reader, please print the form and fax. Submit by Email Print Form Date (MM/DD/YY) / / FOR UM/JMH FTC USE ONLY: Date Received (MM/DD/YY) Recommendation Acardiac Twin Referral Form - Rev. 8/09 / / Diagnosis Follow Up Page 1 of 2 MEDICAL INFORMATION DATE (MM/DD/YY) AGE / / GRAV Twins PARITY Triplets LMP / Maternal Weight / EDC / / GA: weeks lbs Placenta Amniotic Fluid Placenta is located on which uterine surface: Maximum vertical pocket in each sac Anterior Fundal Posterior Amniocentesis Genetic Yes If yes, karyotype Therapeutic Yes Acardiac cm Pump twin cm Cervical Length No 46, XX days 46, XY Cervical length via transvaginal ultrasound: Unk No cm Funneling? Yes No If a therapeutic amniocentesis has been performed, please provide the following information: Date Amount MM/DD/YY Removed Fluid Color Placenta Penetrated Outer Membrane Detachment Disruption of dividing Membrane Uterine Contractions Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Triple Screen Incompetent Cervix Is there an increased risk for: History of an incompetent cervix? Yes No Cerclage in current pregnancy? Yes No Down Syndrome? Yes Neural Tube Defect? Yes No No Fetal Hydrops Pre-term Labor Symptoms of pre-term labor? Yes No Yes No List symptoms Medications for pre-term labor administered? List medications Biometry Discordance Does the pump twin exhibit evidence of: Ascites Yes No Scalp edema Yes No Pleural effusion Yes No Pericardial effusion Yes No Poor contractility Yes No Measurement of the abdominal circumference (including skin edema) Acardiac cm Pump twin cm Medical History Please list any pertinent medical conditions, including bleeding disorders How did you hear about us? Referral Name? Medications Acardiac Twin Referral Form - Rev. 8/09 Website Insurance provider list Media Brochure/flyer/mailing Other Page 2 of 2