Refer Your Patient for Genetic Counseling - UT Physicians

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Refer Your Patient for Genetic Counseling

The Advanced Reproductive Genetics Program provides expert preconception and prenatal genetic counseling for all families across Texas. Our program is proud to offer telemedicine and in-person consultations. To speak with our scheduling team about a referral to a certified genetic counselor, please call 713-486-9302.

To refer your patient, please complete the forms below and attach or fax the patient's medical records, including labs, ultrasounds, and patient demographics.

If you prefer to fax your referral, please complete our patient referral form, and fax it along with your patient's medical records to 713-512-7100.

Please note that patients must be physically within the state of Texas during their telemedicine genetic counseling consult.

Thank you for entrusting and partnering with our team to care for your patient.
Patient Information
Patient's Name*
Patient's Date of Birth*
Month
Day
Year
Patient's Contact Phone*
Patient's Email
Patient's Preferred Language
Patient's Next Appointment with Referring Provider (if applicable)
Insurance Information
Accepted file types: pdf, jpg, gif, png, Max. file size: 20 MB.
Referring Provider Information
Referring Provider Name*
Office Phone Number*
Office Fax Number*
Preferred Office Contact
Indication
Preconception or Prenatal*
- Preconception
- Prenatal
Estimated Date of Delivery (if prenatal)
Indication for Referral*
Other Information
Is there any additional information we need to know?
Health Records File Upload
Accepted file types: pdf, jpg, gif, png, Max. file size: 20 MB.
UT Physicians uses Transport Layer Security (TLS) encryption (also known as HTTPS) for all transmitted data. We also protect all individual internal form data with passwords. Our data is hosted by data centers that are SSAE-16 SOC II certified.
Phone
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