Maternal Fetal Medicine NEW PATIENT REGISTRATION

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

NEW PATIENT REGISTRATION INFORMATION

In order to facilitate your visit, we request that you please read through the following information and answer some questions about your medical

history as it pertains to your upcoming visit.

If you need to cancel or change your appointment, please provide a minimum of 24 hour notice.

Medical records and a referral from your medical provider are required prior to making an appointment, in order to ensure that you’re scheduled for

the appropriate evaluation. Our staff will make every effort to obtain records in a timely manner, so as not to delay your medical treatment.

Please bring with you: a picture ID, insurance card, a referral form from your medical provider (unless already sent electronically by your medical

office), and a copy of any other medical records/labs that you consider pertinent to your care that may not be available from your obstetric office (for

example, Cardiology evaluation, Rheumatology records, etc).

Please arrive 15 minutes prior to your appointment to allow for completion of the registration process, vital signs, etc.

OFFICE INFORMATION:

We’re open Monday – Friday (except for major holidays) from 8am to 4:30pm. Appointment times vary depending on the service provided.

For approximate times of most common appointment types please see below:

Ultrasound (longer times will be allotted for twin pregnancies)

 First Trimester Nuchal Translucency Screening – 30-45 minutes, 15-60 minute counseling session

 First trimester dating ultrasound – 30 minutes

 Fetal anatomy ultrasound – 45-60 minutes

 Growth ultrasound – 30 minutes

 Biophysical profile – 30 minutes; 50-60 minutes with non-stress test (NST)

Consultations

 MFM – 30-60 minute initial consultation, 15-30 minute follow up appointments

 Genetic consultation – 30-60 minutes

 Preconception counseling – 45-60 minutes

Other Procedures and Services

 Amniocentesis – 30 minutes, 15-60 minute genetic counseling session

 CVS (chorionic villus sampling) – 30 min, 15-60 minute counseling session

 NST (non-stress test) – 20-30 minutes

 Diabetes management (physician appointments are made for ~1 week post receipt of glucometer):

*Diabetic log sheets can be obtained online at www.sibley.org/MFM

*Please bring a copy of log sheets to all of your appointments. We will also need information on your current medication

regimen and the timing of medication administration

*For refills on lancets and test strips, please provide your glucometer name (i.e. OneTouch Ultra) and lancing device name (i.e.

Delica)

LATE ARRIVAL POLICY:

All patients are asked to arrive 15 minutes before their scheduled appointment time. Your appointment time is when your

evaluation is scheduled to start (i.e. an ultrasound). Arriving a few minutes prior allows time for check in and vitals. Due to

the nature and duration of the scheduled exams, those arriving 15 minutes or more after their scheduled appointment time

will, in most cases, be rescheduled to the next available appointment. We will make all reasonable efforts to provide this

appointment the same day, but it may be several hours later or possibly a different day altogether. Strict adherence to this

policy allows us to provide quality care and to dedicate the required amount of time to appropriately assess the wellbeing of

you and your pregnancy.

Please initial and date here __________________ to acknowledge that you have read and understand the Late Arrival Policy.

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

GENETIC CONSULTATION INFORMATION

To Our Prospective Patients,

During the course of your care in our office, you may meet with a genetic counselor.

About Genetic Counselors and Genetic Consultation

A genetic counselor is a healthcare professional with a specialized graduate degree, certification, and experience in genetics

and counseling. You may be referred by your doctor to meet with a genetic counselor due to your medical, pregnancy, or

family history, or due to an increased risk based on age, test results, ultrasound findings, exposures, or other factors. You

may also be referred to meet with a genetic counselor by the Maternal Fetal Medicine specialist.

During a genetic consultation and follow up, a genetic counselor will:

 discuss potential genetic risks and available testing options

 provide you with a personalized risk assessment based on your medical, pregnancy, and family history

 explain test results

 provide you with information about a chromosome abnormality, birth defect, or genetic condition of concern

 support you in making decisions about testing options and pregnancy

 coordinate genetic testing, if available and desired

 provide you with referrals to other specialists or resources, as needed

At times, a genetic counseling student may participate in your care. A certified genetic counselor will be present during all

student interactions to ensure that you receive clear and appropriate information. You always have the option to decline

interaction (observation or counseling) with a genetic counseling student. If a genetic counseling student is present, the

same billing policies described below will apply.

About Billing for Genetic Consultation

The cost of a genetic consultation will be billed to your insurance based on the amount of time you spend talking with the

genetic counselor (divided into 30 minute increments). When possible, codes are submitted to your insurance company for

pre-authorization and approval prior to the consultation. If you would like to contact insurance personally to determine

coverage, please use the CPT (procedural) code 96040 for genetic consultation. This is the only CPT code that can be used

for genetic consultation and therefore, if your insurance carrier does not cover this CPT code, a different code cannot be

used and genetic consultation will not be covered. Please understand that pre-authorization or approval for genetic

counseling is NOT a guarantee that the cost of the consultation will be covered by insurance. There are some insurance

companies that do not routinely cover genetic counseling. Please understand that meeting with a genetic counselor is

required prior to having certain genetic tests in our office, including cell-free DNA screening, carrier screening, chorionic

villus sampling (CVS), and amniocentesis.

If you receive a bill for genetic consultation, you will be eligible to receive a discount for self-pay. Please contact Patient

Financial Services at 202-537-4778 to have the discount applied and to pay your bill.

If you receive a request for medical documentation supporting the need for genetic consultation or testing, please contact

our genetic counselor at 202-660-7182.

Thank you!

The Maternal Fetal Medicine Program at Sibley Memorial Hospital

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

FIRST TRIMESTER SCREENING AND BILLING

The first trimester screen provides a risk assessment for Down syndrome and two other more severe chromosome

abnormalities (trisomy 18 and trisomy 13) in the end of the first trimester of pregnancy (weeks 12-13

). The first trimester

screen combines the results of a specialized ultrasound (nuchal translucency) with a blood test. The ultrasound will be

performed in our office at the time of your appointment and your blood will be drawn and sent to NTD

laboratories/PerkinElmer for analysis. There are several laboratories that offer first trimester screen blood analysis,

HOWEVER, our office will ONLY send a blood sample for first trimester screening to NTD laboratories. We use NTD

laboratories because their first trimester combined screen result is the most accurate, detecting up to 95% of cases of Down

syndrome, trisomy 18, and trisomy 13 (compared to a detection rate of 85% at some other laboratories). Regardless of which

laboratory is in network for your insurance carrier, your first trimester screen blood work will be sent to NTD to provide

the risk assessment with the highest accuracy. If your insurance carrier is out of network and you do not have out of network

benefits, your first trimester blood sample cannot be sent to a different in network laboratory. You may wish to call your

insurance carrier prior to your first trimester screen appointment to determine if your insurance carrier is contracted with

NTD laboratories/Eurofins. You may decline first trimester screen blood analysis, however, the most accurate test result is

produced from combining the ultrasound results with blood analysis. Please ask the physician and/or genetic counselor if

you have further questions at the time of your appointment.

The cost of the first trimester screen blood work through NTD laboratories is $260. If you receive a bill for some, or all, of

this amount, you will be eligible for a discounted self-pay rate (typically less than $100). Please contact NTD Laboratories

directly at 631-425-0800 to discuss the discounted rate and to pay your bill.

If you receive a request for medical documentation supporting the need for first trimester screening, please contact our

genetic counselor at 202-660-7182.

Please read the statement below, and print, sign, and date if you agree.

I have read and understand the first trimester screen and genetic consultation billing policies of the Maternal Fetal

Medicine Program at Sibley Memorial Hospital.

Patient’s Name Patient’s Electronic Signature Date

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

HELPFUL LINKS

For information regarding your visit at Sibley Memorial Hospital, please visit:

https://www.hopkinsmedicine.org/sibley-memorial-hospital/ or https://www.hopkinsmedicine.org/sibley-

memorial-hospital/planning-your-visit/

If you have any questions, please contact our office at 202-660-7180 for assistance.

Patient education information can also be accessed on our website, at www.sibley.org/MFM

Thank you!

The Maternal Fetal Medicine Program at Sibley Memorial Hospital

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD,

FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

PATIENT REGISTRATION INFORMATION

First Name: _______________________ Middle Name: __________

______ Last Name: ___________________________________

Date of birth: ____________________ Social Security Number: ______________________________________________________

Country of Birth: ____________________________ Maiden Name: ____________________________ (*for security purposes only)

Address: ___________________________________________________________________________________________________

City: __________________________________________ State: ____________________ ZIP Code: ________________________

Home #: _______________________ Work #: _________________________ Cell #: __________________________________

Email: ________________________________ Marital Status: ___________________ Occupation: ________________________

Employer: ___________________________________ Employment Status (check one): full time / part time/ other:_________

Ethnicity (check one): Hispanic/Latino or Not Hispanic/Latino Race: ________________________________________

Partner/Spouse Information:

First Name: _______________________ Middle Name: ________________ Last Name: ___________________________________

Date of Birth: _________________ Age: _________________________ SSN _________________________________________

Race: ________________________________________ Phone #: ____________________________________________________

Employer/Profession: _____________________________ Employment Status: full time / part time / other: ______________

Emergency Contact: (if different from spouse/partner above)

Name: ___________________________ Relation to the Patient: ______________________ Phone #: _______________________

Insurance Information: (*please include a front and back copy of your insurance card when sending in this form*)

Insurance Provider ____________________________ Covered through (check one): current employer / other: ___________

Plan (check one): HMO / PPO / Open Access / Choice Plus / Federal Employee / other: _____________________

Subscriber/Member ID#: ___________________________________ Group #: __________________________________________

Address (PO Box #) on back of card for Medical Claims: _____________________________________________________________

Is the insurance plan through your spouse/partner’s employer (check one): yes no

Referral Information:

Referring Physician ______________________________ Phone*: _____________________ Fax*: ___________________________

(*Phone and fax information is not necessary for physicians affiliated with Sibley Memorial Hospital)

Reason for Referral (as stated on the referral form): __________________________________________________________________

First Day of Last Menstrual Period: _______________________________________________________________________________

Specialist Information:

Are you seeing a specialist provider (e.g. rheumatologist, hematologist, neurologist, cardiologist, endocrinologist, etc)? Yes No

Within the past 5 years, have you seen a specialist provider? Yes No

If yes

* to any of the above, please list their name: _________________________ Phone: _______________ Fax: ________________

(*Please contact your specialist provider and request records to be sent to our office - fax: 202-660-7189)

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

MEDICAL HISTORY QUESTIONNAIRE

Name: ____________________________________________________________________________________

Age: _________________________________ Due Date:_______________________________________

Please tell us your understanding of the reason for referral to high risk obstetrics. ________________________

__________________________________________________________________________________________

List any complications thus far during this pregnancy (i.e. bleeding, cramping, etc.):______________________

__________________________________________________________________________________________

MEDICAL HISTORY:

Do you have any medical problems?

CONDITION

YES

YEAR DIAGNOSED

COMMENTS

Anemia

Asthma

Back problems

Blood clots

Blood transfusion

Cancer

Anxiety

Depression

Diabetes

Heart problems/murmurs

Hepatitis or liver disease

High blood pressure

Kidney disease/recurrent UTI

Lupus or other autoimmune

disorders (please specify)

Migraines

Seizure disorder

Thyroid problems

(please specify hypo or hyperthyroidism)

Other:

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

SURGICAL HISTORY:

Have you had any surgeries or procedures?

DATE OF

SURGERY

SURGERY TYPE/

REASON FOR SURGERY

ANESTHESIA

(GENERAL OR

LOCAL)

ANESTHESIA

COMPLICATIONS

COMMENTS

OBSTETRIC HISTORY:

If IVF, date of embryo transfer? ___________________ Infertility treatment center ______________________

Please tell us about your pregnancies:

TOTAL # OF

PREGNANCIES

(INCLUDE CURRENT)

FULL TERM

(37+ WEEKS)

PREMATURE

(<37 WEEKS)

SPONTANEOUS

MISCARRIAGES

TERMINATIONS

MULTIPLE

BIRTHS

ECTOPIC

PREGNANCY

LIVING

CHILDREN

PREGNANCY

DATE

WEEKS

DELIVERY

BIRTH

WEIGHT

MALE

FEMALE

VAGINAL,

CESAREAN,

FORCEPS

OR VACUUM

TYPE OF

ANESTHESIA

COMMENTS/

COMPLICATIONS

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

Any children with birth defects (heart defects, neural tube defects, cleft lip/palate, etc.)? _________________________

__________________________________________________________________________________________

Any children with developmental delay, autism, or Down syndrome? __________________________________

__________________________________________________________________________________________

GYNECOLOGIC HISTORY:

Age at onset of menses: _________________ Regular cycles? _______________________________________

History of HSV (herpes), gonorrhea, chlamydia, or syphilis? _________________________________________

Does your partner have HSV (herpes) or HIV? ___________________________________________________

Date of last PAP smear: ______________________________________________________________________

History of abnormal PAP smear? _____________ if yes, what year? ___________ HPV positive? _________

Any treatment of the cervix (biopsy, excisional cone/LEEP, cryotherapy)? ____________________________________

SOCIAL HISTORY:

Do you smoke or have you ever smoked cigarettes? _______________________________________________

If yes, how much and for how long? ______________________________________________________

Do you drink alcohol? ___________ if yes, how much?_______________ during pregnancy? _____________

Do you or have you used recreational drugs? _____________________________________________________

If yes, what drugs, how much, and when?__________________________________________________

Have you had exposures to chemicals, pesticides, X-rays, or cat litter box during this pregnancy?____________

If yes, please list type of exposure, duration, and date(s) of exposure:____________________________

___________________________________________________________________________________

Have you had exposure to infections during this pregnancy (i.e. fever, rash, etc.)?___________________________

If yes, please list type of exposure, duration, and date(s) of exposure:____________________________

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

FAMILY HISTORY: (please mark any that apply with an “X”, be as specific as possible – ex: maternal grandfather)

YOUR

MOTHER

YOUR

FATHER

YOUR

BROTHER

OR SISTER

(circle one)

OTHER

CHILD

(write in

gender)

OTHER

RELATIVE

FATHER OF

BABY

COMMENTS

Birth defects

Blood clotting

disorder

Blindness

Congenital heart

defect

Cystic fibrosis

Chromosomal

disorder

Cleft lip or palate

Diabetes

Deafness

Dwarfism

Early onset cancer

Galactosemia

Huntington

disease

Heart problems

Hemophilia

High blood

pressure

Hydrocephalus

Intellectual

disability, autism,

Down syndrome,

Fragile X

syndrome

Infant or

childhood death

Kidney problems

Multiple (3 or

more)

miscarriages

Muscular

dystrophy

Neural tube defect

Phenylketonuria

Other metabolic

disease

Sickle cell disease

Thalassemia

Tay Sachs disease

or carrier

Thyroid problems

Any other:

Have you or your partner had genetic screening?(if yes, please explain) _____________________________________

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Driggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

ALLERGIES:

Are you allergic to any medications? _____________ (if yes, please list medication name and reaction below)

MEDICATION

ALLERGIC REACTION

(ex. rash, difficulty breathing, swelling)

Do you have LATEX allergies? (if yes, include reaction)_______________________________________________

Are you allergic to IODINE? (if yes, include reaction) _________________________________________________

HOME MEDICATIONS: (please also include over the counter and any herbal medications)

MEDICATION

DOSE/FREQUENCY

CHECK IF TAKEN

DURING PREGNANCY

Maternal Fetal Medicine

Building B, 3

Floor, 5255 Loughboro Road NW

Washington, DC 20016-2695

Phone: 202-660-7180 Fax: 202-660-7189

Rita W. Dri

ggers, MD, FACOG (Medical Director) Julia Timofeev, MD, FACOG Christopher Novak, MD, FACOG

REVIEW OF SYSTEMS (symptoms you are currently experiencing)

General

܆ Weight loss

܆ Fever or chills

Skin

܆ Rashes

܆ Itching

Head

܆ Headache

Eyes

܆ Vision Loss/Changes

܆ Blurry or double vision

܆ Flashing lights

Nose

܆ Stuffiness

܆ Itching

܆ Nosebleeds

Throat

܆ Bleeding

܆ Sore throat

܆ Non-healing sores

Neck

܆ Swollen glands

܆ Pain

Breasts

܆ Lumps

܆ Discharge

Respiratory

܆ Cough

܆ Coughing up blood

܆ Shortness of breath

܆ Wheezing

܆ Painful breathing

Cardiovascular

܆ Chest pain or discomfort

܆ Tightness

܆ Palpitations

܆ Shortness of breath at rest

܆ Swelling

Gastrointestinal

܆ Heartburn

܆ Nausea/vomiting

܆ Rectal bleeding

܆ Constipation

܆ Diarrhea

Urinary

܆ Burning or pain

܆ Blood in urine

Vascular

܆ Calf pain with walking

܆ Asymmetric swelling

Musculoskeletal

܆ Muscle or joint pain

܆ Back pain

܆ Redness of joints

Neurologic

܆ Fainting

܆ Seizures

܆ Numbness

܆ Tingling

Hematologic

܆ Ease of bruising

܆ Ease of bleeding

Endocrine

܆ Sweating

܆ Thirst

Psychiatric

܆ Nervousness/anxiety

܆ Stress

܆ Depression

□ Other _______________________________________________________________________