Reproductive Genetic Services
Division of Maternal Fetal Medicine
Department of Obstetrics & Gynecology
www.columbiaobgyn.org
Date: _______________________
Dear: ____________________________________________,
Thank you for choosing Reproductive Genetic Services, Division of Maternal Fetal Medicine. We look forward to seeing
you for your appointment on ___________________________.
In order to complete the process for your procedure appointment, we will require the following lab work. These records
should be faxed to our office three days prior to your appointment.
Our fax # is: 212-326-8784
Blood type and Rh factor
RBC antibody screen (also called “COOMBS”)
- This screen must be drawn during current pregnancy
CBC (complete blood count)
Gonorrhea culture
Most recent ultrasound
If the following lab work has been performed we also request it be sent, but is not required for procedure:
o Any genetic screening that has been performed on you/your partner in this or a previous pregnancy (i.e.
cystic fibrosis, fragile X etc…)
o Hemoglobin electrophoresis
Your appointment will be at the following location:
Columbia Eastside
16 E. 60th Street
Suite 480, 4th Floor
New York, NY 10022
Morgan Stanley Children’s Hospital
3959 Broadway (between 165th & 166th)
CHONY Central, 12th Floor
New York, NY 10032
If you have any questions prior to your appointment please feel free to call: 212-326-8785. Please inform our office, prior to your appointment, if you
are on heparin, fragmin (low weight heparin) or any other anticoagulation therapy or if you have a bleeding disorder.
Please call us at 212-326-8452 if you need to cancel/reschedule your appointment. Please specify the dates when canceling/rescheduling
appointments.
For patients who are scheduled for genetic consultation and procedure, you should expect to be at our office for approximately 2-3 hours.
We ask that you refrain from bringing any children, if possible.
We look forward to meeting you.
**Please fill out the pages of this packet and bring them with you on the day of your appointments. We will need
to make copies of your insurance card and driver’s license for billing purposes.
Reproductive Genetic Services
Division of Maternal Fetal Medicine
Department of Obstetrics & Gynecology
www.columbiaobgyn.org
622 West 168 Street / 161 Ft. Washington Avenue
T/212-305-4636
F/212-305-8131
Center for Prenatal Pediatrics
3959 Broadway, CHONY Central, 12th Floor
T/212-305-3151
F/212-342-2802
16 East 60 Street
T/212-326-8954
F/212-326-8955
Westchester
T/914-337-2102
F/914-337-5666
GENETICS APPOINTMENT INTAKE
MRN: ____________________
Referring MD: _____________________________________
Tele: ___________________
Name of Patient: ___________________________________
DOB: ________________
Name of Partner: ____________________________________
DOB: ________________
Reason for Referral: _____________________________________________________________________
LMP (or Date of Retrieval if IVF): _____________
EDD: ___________ # Fetuses carrying: _________
Blood Type:____________
Taking blood thinners? (Heparin/Lovenox):_____________________
Tele:
W _____________________
H ____________________
C _____________________
Address:_______________________________________________________________________________
Has patient had genetic counseling before?
□ Yes
□ No
If yes, was GC in the current or a past pregnancy? __________________
Name of GC or institution: _____________________ Phone number __________________
Insurance Information:
Policy Holder: _________________________
Policy #: ______________________________
Insurance Company: ____________________
Group #: ______________________________
Insurance Claim Address: _________________
Policy Holder SS #: _____________________
______________________________________
Policy Holder Tel: ______________________
Ins Co. Phone #: ________________________
DOB: _________
Appt Date & Time: _____________________________________
Relationship ________
For Fetal Reductions
(to be filled out by Genetic Counselor)
Intake done by: _____________________________
Appt made with: □ Physician’s office
□
□ Patient
Records requested (if not in WebCis or Digi): Blood type, current antibody screen, CBC,
hemoglobin electrophoresis, gonorrhea culture for CVS, U/S report, and genetic carrier
screening results (such as cystic fibrosis)
Name of contact person at MD office _________________ Packet mailed_________
Allergy to Penicillin/Keflex? ___________
Allergy to Sulfa antibiotic? ____________
Pharmacy Phone #
__________________________________
Date prescription called in _____________
Reproductive Genetic Services
MFMF
212.305.3278
212.305.8131
GENETIC COUNSELING QUESTIONNAIRE
www.columbia.edu
Date: ______________________
Please complete the following questionnaire.
This information will be reviewed during your genetics consultation.
MRN: _________________
Referring MD: ____________________________________
Tele: _________________________
Name of Patient: ___________________________ DOB: ______________
Age: ____________
Reason for Genetic Counseling: __________________________________________________________________
Street Address: ________________________
Tele:
City/State: _____________
Zip Code: ________________
H _________________ W _________________ C _____________________
Ethnic Background: ___________________________
Name of Partner: ___________________________
Ethnic Background: ___________________________
Are you currently pregnant? ______________
Profession: ____________________
DOB: ______________ Age: ____________
Profession: ____________________
What is your due date? _________________
When was the first day of your last menstrual period? ___________________
Did you seek the assistance of fertility specialists for your current pregnancy? _______________
How many times have you been pregnant in total? ______________________
Have you had any miscarriages, stillbirths or a baby that died in infancy? ___________________
Did you take any medications during this pregnancy? _____ If yes, what are the names of the medications:
_____________________________________________________________________________________
Did you drink any alcoholic beverages during this pregnancy? _____________
Are you a smoker or non-smoker? ________________
Do you or your partner have any chronic health problems, such as: diabetes, high blood pressure, ect?
__________________________________________________________________________________
Have you or your partner had a child with abnormality or birth defect? ____________________________
Do you, your partner, or any members of your families have any of the following:
 Birth Defect
 Anemia (Sickle Cell/Thalassemia)
 Spinal Bifida
 Cleft Lip/Palate
 Muscular dystrophy
 Mental Retardation
 Hearing Loss
 Blindness
 Kidney Disease
 Other Genetic Problem:
 Seizures
_______________________________
 Bleeding Problems
Have you ever undergone prenatal diagnosis through CVS or Amniocentesis in the past? __________________
PATIENT REGISTRATION
Last Name __________________________ First Name ____________________ MI ________
Address ___________________________City/State ___________ Zip Code ______ Apt. # ____
Telephone – Home __________________Cell ___________________Work ________________
Email Address _________________________________DOB ___/___/___ SS # _____________
Father’s 1st Name _______________ Mother’s 1st Name _______________Marital Status ______
Employer Name & Address ______________________________________________________
Pharmacy Name & Phone _______________________ PCP Name & Phone ________________
INSURANCE INFORMATION
1. Insurance Name _________________________________________________
Insurance ID ________________________________ Group # ___________________
Subscriber’s Name _________________________ Subscriber’s D.O.B. ___________
2. Insurance Name _________________________________________________
Insurance ID ________________________________ Group # ___________________
Subscriber’s Name _________________________ Subscriber’s D.O.B. ___________
I, ________________________________________________ (Please Print) authorize the Department of Maternal Fetal Medicine to
release any medical information required to properly adjudicate my health insurance claim(s). I also understand that my referring
physician, which I have listed below will be provided with a copy of any reports generated as a result of the requested diagnostic test
and/or procedures.
Referring Physician Name: __________________________________________
Address: __________________________________________
__________________________________________
Phone Number: __________________________________________
Fax Number: __________________________________________
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. I authorize the release of information necessary
to process any claims.
Patient (or Responsible Party) Signature _______________________ Date__________