Options Center Referral

To schedule your patient for an appointment, please complete this referral form.  To ensure your patient is scheduled quickly and appropriately, we also kindly request that you send any of the following that you have available for the patient.    Fax all forms to 808-686-2127.

• Labs- taken within 30 days of referral
  • CBC with diff
  • Type and screen
  • Ultrasound: requested for all patients, required for all neighbor island patients
    • Measurements needed:
      • EGA 5wk-6wk: Gestational sac/yolk sac
      • EGA 6wk-14wks: Crown Rump Length
      • EGA 14wks-22wks:
        • Full Biometry
        • Head Circumference
        • BPD
        • Abdominal Length
        • Femur Length
  • Handwritten measurements are acceptable if a picture with visible measurements is also included
• Most recent progress note
• Names of specialists managing any significant comorbidities; notes from specialists appreciated
• Patient’s demographics including:
  • Name
  • DOB
  • Insurance type and subscriber  number
  • 2 working contact numbers