MULTCO Client Referral

Client Info

Client Full Name *

Phone *

Email

Client DOB: *

Which MULTCO clinic are they in? *

Name of the Birth Location *

Legacy Mt Hood (LMH)

Legacy Emanuel Hospital (LEH)

Legacy Good Sam (LGS)

Other

If selected "other" in hospital location write answer here.

Estimated Due Date (EDD) *

Language / interpreter needs

Last Menstrual Period: *

Any KNOWN Pregnancy Concerns (Gestational Diabetes, Twins/Multiples, Pre-Eclampsia etc)

Street Address

City

State

Postal Code

Insurance Info

Primary Insurance ID *

Primary Insurance *

Secondary Insurance (if applicable):

Secondary Insurance ID

Subscriber Name/DOB (if different from client):

Secondary Insurance Subscriber Name/DOB

The following is an authorization for referral form. Please review and sign.

Consent: I confirm that I have discussed doula services with named patient above, and they have given verbal consent for referral to Gateway Doula Group.

The patient understands that:

Receiving Doula Support is voluntary and may be declined at any time
Relevant information may be shared for the purpose of coordinating care and billing, as permitted

Provider Referrer Name {Printed) *

Provider Title *

Signature *

Clear

Date *

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