PORT MOODY MATERNITY CENTRE Tel: 604-949-7248    Fax: 604-949-7249 Port Moody Maternity Centre #200 - 205 Newport Drive Port Moody, BC, V3H 5C9 Referring Physician: PATIENT INFORMATION: DATE: NAME: HOME PHONE: DOB: WORK PHONE: PHN: CELL PHONE: ADDRESS: G: T: P: Ect: SA: TA: L: LNMP: (yyyy-mm-dd) EDC: Certain Uncertain PLEASE ENSURE THAT PMMC HAS BEEN COPIED ON ALL LAB WORK AND RADIOLOGY EXAMS ORDERED Dating US: Ordered - Location: Done Report Attached NT Scan: Ordered - Location: Done Report Attached SIPS/NIPT/FTS: Discussed and requisition given Discussed and declined Reference Not discussed Routine PN Labs*: Ordered Done Report Attached Not Ordered [*CBC, TSH, Rubella titre, STS, HBsAg, Blood type-group + screen, HepC Ab, Varicella Ab (if status unknown), HIV (with consent), urine C&S] Please also include the following with referral: * Prenatal records from your office * Previous Obstetric or Surgical reports * Last Pap smear and any relevant C&S reports Medications: ▲ ▼ Allergies: ▲ ▼ Past Obstetrical History: ▲ ▼ Past Medical/Surgical History: ▲ ▼ Comments: ▲ ▼ Your patient will be contacted directly with an appointment as soon as documents have been received.