Village Perinatal is your best maternal fetal medicine partner in collaborative pregnancy care.

Click here for Referral Form.

If you want us to send you the Village Perinatal Referral Packet, including a tablet of Referral Forms pre-printed with your office information, please call our Office Manager Chinue Joy Black at 323.871.2214.

Referral Instructions

Please fax the completed Referral Form and a copy of the patient’s Insurance Card to
323.871.4214. No fax cover sheet is necessary.

Once we have scheduled the patient, we will return an Appointment Confirmation Letter to your office via fax with the patient’s appointment date and time.

Notes about the Referral Form:

• Please complete this form in its entirety. Insurance information and multiple phone numbers, if available, help us schedule your patient’s visit in a timely manner.
• If the Referring Physician/Provider section is not filled in, or if only your clinic name is listed, please fill in the name of the Referring Physician.
• EDD is specified as either EDD by LMP or EDD by Ultrasound. Please specify the method used. For example: EDD by LMP: 06/13/10
• Common Services Requested and Indications have been listed for your convenience. Please check the boxes that apply. If the indication for which you are referring is not listed, please fill in the Other and Additional Comments sections as necessary.

We want to make this process as easy as possible for your staff, and we welcome your questions and feedback. We can also send you these instructions and forms in hard copy. Please call our Office Manager Chinue Joy Black at 323.871.2214.