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.

*Please include patient demographics, office notes, prenatal records, labs, and ultrasound reports.





Reason for Referral (check all that apply):

Preferred Appointment Format:

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