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Refer Your Patient to UTHealth Houston Fetal Center

The mission of The Fetal Center is to manage and streamline the care for pregnant patients diagnosed with a fetal anomaly requiring coordinated care or fetal intervention through a simple phone call. All fetal imaging, genetic testing (if applicable), and pediatric sub-specialty appointments are arranged by the Fetal Center's dedicated nurse coordinators, and a transfer of obstetrical care may be arranged at your request.

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

Our Fetal Center Physicians are available 24 hours a day, seven days a week. To speak with a clinical specialist about a referral, please call (832) 325-7288.
Referring Physician Name*
First Last
Office Contact Phone*
Referring Physician Phone*
Patient's Name*
First Last
Patient's Contact Phone*
Patient Date of Birth*
Month
Day
Year
Estimated Date of Delivery
Gestational Age
Insurance/Policy Information (if available)
Please provide carrier and policy number.
Referring Diagnosis
Any additional information we need to know?
Health Records Submission Method*
Prenatal records, labs and imaging studies help our team to identify the most appropriate appointment for your patient. Please indicate how you are submitting supporting clinical documentation.
- I am attaching supporting clinical documentation to this referral form
- I prefer to fax supporting clinical documentation to (713) 383-1464
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.
Name
This field is for validation purposes and should be left unchanged.