Referral Forms

Forms

The  above forms are for use by referring physicians. To refer a patient, please:

• Acardiac and Anomalous Twins / TRAP
• Chest Mass (CPAM, BPS, Pleural Effusion, etc.)
• Fetal Transfusion
• LUTO-Bladder Obstruction
• Myelomeningocele
• PROM (iatrogenic)
• TTTS and SIUGR
• Miscellaneous

For Referring Physicians

Please complete the appropriate referral form and fax it to our office at (213) 469-6279 along with:

• Completed referral form
• Recent consultation notes and ultrasound reports
• Patient demographic information
• Insurance information
• Prenatal records

Once the records are reviewed, one of our nurse coordinators will contact the patient to schedule an appointment or reach out to you if additional information is needed.

For clinical questions, you may contact Dr. Ramen Chmait directly at chmait@usc.edu

Office: 213-469-6277

Fax: 213-469-6279