New Patient Supporting Documents for the Young Mothers and Families Clinic

Diagnosis /Symptom: Pregnancy under 21

What should the referring provider send?

1. Positive urine pregnancy test
2. Acceptance by patient to be seen for prenatal care
3. Ultrasound if performed
4. Medical records if complex patient history
5. Any medical information if MOC has one or more of the following:
   Depression
   STDs
   High Risk Social Circumstance

Diagnosis /Symptom: Newborn of Teen Mother under 21

What should the referring provider send?

1. Mother’s medical records related to labor and delivery
2. Summary of prenatal labs
3. Any notable concerns during prenatal care
4. Baby’s records related to Neonatal course in nursery
5. Lab results for newborn
6. Any medical information if MOC has one or more of the following:
   Depression
   STDs
   High Risk Social Circumstance