REFERRAL FORMS

Dear Doctor,

Thank you for referring your patient to the CHLA-USC IMFH Fetal Therapy Program at Hollywood Presbyterian Medical Center. We look forward to working with you and your patient. Please see below the referral forms, which you may fax to our office. Terri Maitino, RN, the Fetal Therapy Coordinator, will contact you upon receipt of your fax.

If you have any questions, please feel free to contact Terri at (323) 671-6074 or (813) 841-7218, or email me directly at chmait@usc.edu.

Regards,

Ramen Chmait, MD
Director of Fetal Therapy
Childrens Hospital Los Angeles / University of Southern California
Institute for Maternal-Fetal Health at Hollywood Presbyterian Medical Center

REFERRAL FORMS (PDF files):

• Thoracoamniotic Shunt »
• Acardiac Twin »
• Bladder: Lower Obstructive Uropathy »
• Fetal Transfusion »
• PROM »
• Twin-Twin Transfusion Syndrome (TTTS), or Monochorionic Twins with Selective Intrauterine Growth Restriction »

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