Parent Connection Request on Behalf of Your Patient

Welcome. Thank you for connecting your patient with a National Prenatal First Call parent who received a suspected or confirmed prenatal diagnosis. The phone conversation with your patient will be confidential. If you have any questions about completing the form, you may email nationalfirstcall@mdsc.org

* = required

About You

First Name*

Last Name*

Email

Specialty*

About Your Patient's Pregnancy

Has your patient received a diagnosis of Down syndrome through a CVS or amniocentesis?*

Yes
No

Due Date*

Approximate number of weeks gestation/pregnancy today*

Has your patient received prenatal screening test results (involving bloodwork and ultrasound) that indicate a higher chance that the baby has Down syndrome?*

Yes
No

Additional Optional Information

Please share the following information to help us make the most meaningful connection when possible:

Ethnicity of Parent(s):

Primary Language:

We may be able to connect them with a bilingual First Call parent

Any health/medical information about the baby and/or pregnancy that could be helpful to us when matching them with a parent volunteer?

Location Information

All personal information will be kept confidential and will not be shared.

Address

Street Address Address Line 2 City

Address*

State / Province / Region

Preferred Contact Method

Would your patient prefer that we:*

email them to arrange a time to talk by phone
text them to arrange a time to talk by phone

Please share any additional information that may be helpful to us before connecting them with a First Call parent:

Consent Form

Consent*

I have reviewed the waiver and consent

Please review this waiver/consent with your patient.

MEDICAL PROVIDER MUST CHECK BOX OR SIGN FORM

My patient understands that they will be speaking with a trained parent volunteer and that this conversation does not represent medical advice or professional counseling. The National Prenatal First Call Center does not provide advice in any way. Their conversation(s) with a parent volunteer will be confidential and only a brief synopsis of their call(s) may be shared with the Family Support Team of the National Center to ensure individualized resources and supports are provided to them. Their personal information will not be shared and will be kept confidential within the National Prenatal First Call Center.

If your patient has not heard from a First Call parent in 24 hours you or they may email us at nationalfirstcall@mdsc.org

Lastly, we are curious how you heard of the National Prenatal First Call Center?*

Parent Connection Request on Behalf of Your Patient