Provider Referral Form

DR. HEATHER L. MERTZ, MD
JENNIFER RASCH, NP
Maternal Fetal Medicine

We are happy to accept referrals via phone, fax, or email. We offer telehealth options and in-person care.

Patient's Full Name:

Patient's DOB:

Patient's Phone Number:

Patient's Email:

Patient's Address Line 1:

Patient's Address Line 2:

Insurance Provider:

Insurance ID Number / Policy Number:

Referring Provider:

Referring Practice:

Referring Practice Primary Contact Name:

Referring Practice Primary Contact Phone Number:

*Please also email patient demographics, office notes, prenatal records, labs, and ultrasound reports directly to FrontDesk@mertzmfm.com.

Reason for Referral (check all that apply):

Preconception Consultation

Poor Prior Pregnancy Outcome

Recurrent Pregnancy Loss

Increased Maternal BMI

Advanced Maternal Age

Diabetes Management

Medication Management

Maternal Medical Conditions

Other

Preferred Appointment Format:

In-Person

Telehealth

Patient Choice

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