Elective Repeat C-Section Referral Form Page 2

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Request to UNC providers
Patient with prior c-section desires Elective Repeat C-section.
Please schedule consultation prior to 36 weeks.
Patient at high risk of uterine rupture: (Prior classical, T or high transverse incision; Prior uterine rupture;
Myomectomy with extensive transfundal uterine surgery)
Please schedule OB consultation prior to 30 weeks.
Scheduling:
Please schedule for OB consultation
OR
Consultation has been scheduled
Call 919-966-2131 ext 1 to schedule
Please fax this form with the prenatal record, dating ultrasound and operative report to the UNC Hospital
Obstetrics Clinic at 919-966-6356.
OB Consult Appointment Date: ___________________________________
Time: ___________
Completed form faxed back to referring clinic on date: __________________

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