Elective Repeat C-Section Referral Form

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Elective Repeat
C-section Referral Form
FAX TO UNC OB CLINIC AT 919-966-6356
Patient Name: _______________________________
Referring provider: ___________________________
Date of birth: _______________________________
Referring clinic: ______________________________
UNC MRN: _________________________________
Referring clinic fax: ___________________________
Please complete this form for a patient with a history of a c-section who is planning an Elective Repeat C-
Section (ERCS) at UNC Women’s Hospital. The purpose of this form is to ensure that providers at UNC have
reviewed the dating criteria for the pregnancy, have access to the operative report for surgical planning, and
have arranged consultation if needed for high risk of uterine rupture or perioperative complications.
Elective Repeat C-Section (ERCS) worksheet
Dating Criteria
LMP: _________________
_________________
“Best” EDC
EDC:
LMP
_________________
________ weeks
_________________
____________________
US:
EDC:
US
Clinical information
Weight: _____
Height: _____
BMI: _____
Number of prior c-sections: ______
Please confirm the following:
The patient is not a candidate for TOLAC
OR
Possibility of TOLAC has been discussed with patient
Patient articulates desire for an Elective Repeat C-Section
Documents attached
Prenatal record, including all labs and ultrasound reports not documented in the UNC EMR
Operative report
Copy of operative report for most recent cesarean section attached
Patient’s more recent c-section was performed at UNC
Operative report is not available
Referring provider signature: ________________________________
Date: _______________________

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