PLEASE REFER PATIENTS BEFORE 14 WK & WITH A DATING ULTRASOUND
* Default contact # is home. Click to choose alternate contact phone #

  • Patient Name:

  • Date of Birth: Family Doctor:  

  • PHN: Office Ph:  

  • Patient Ph: Office Fax:  

  • eMail address:
    • LMP:         G T P A L EDD:
    *Patient must be comfortable with both Male and Female Physicans
    as PCOC operates as a group.     THE FOLLOWING BLOOD WORK SHOULD BE ORDERED AS OUTLINED
    Conception to 12 weeks

    Dating US 7-14wk
    ABO Rh antibodies
    Ferritin
    Hemoglobin
    Urine C/S, CT, GC
    MMR titres
    STS/RPR
    HIV
    HBsAg
    Anti-Hep C
    Anti-VZV
    Part 1 SIPS 9wk - 13wk6d
    12 weeks to 24 weeks

    NT US if pt 35+ at EDC
    Part 2 SIPS 14wk - 20wk6d
    1 hr 50g GTT 24-28wk
    + ABO Rh (repeat)
    + Hemoglobin (repeat)
    + Ferritin (repeat)
    Detailed US 18wk-22wk6d
    24 weeks to 40 weeks

    GBS swab at 36wk
    Subject:

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    Creative Commons License PCOC Referral eForm, update V7_Sep21_2022 by Dr. John Yap, licensed under a GPL.