Refer a Patient

Helping You Educate Your Pregnant and Breastfeeding Patients

Please provide us with the following information so we can contact your patient.

I am referring my patient for:
By checking the box below, you are confirming the patient agrees to be contacted by MotherToBaby:
- Yes, patient agrees to be contacted
Patient's Name
Patient's Email
Patient's Phone
Patient's Language
- English
- Spanish
- French
Referring Provider’s Postal Code*
Patient’s Status:
- Currently Pregnant
- Planning a Pregnancy
- Breastfeeding
If Pregnant, Estimated Due Date:
MM
DD
YYYY
Is your baby less than 2 months old?
- Yes
- No
Does the patient have any of the following medical conditions (check all that apply):
- Ankylosing Spondylitis
- Asthma
- Atopic Dermatitis
- Coronavirus (COVID-19)
- Crohn’s Disease
- Multiple Sclerosis
- Psoriasis
- Psoriatic Arthritis
- RA or JIA
- Ulcerative Colitis
- Other (list in Comments box)
- Patient does not have any health conditions
Comments:
Has the patient been exposed to the COVID-19 vaccine?
- Yes
- No
Has the patient been exposed to the pertussis vaccine?
- Yes
- No
Referred by*
Referring Provider's Phone Number
Your Email
How did you hear about us?
Comments:

Our easy-to-read Fact Sheets on exposures in pregnancy and breastfeeding are available in English and Spanish.

Exposure Information Service
866.626.6847

Pregnancy Studies
877.311.8972

Media Inquiries
619.368.3259
nchavez@mothertobaby.org

MotherToBaby, a service of the Organization of Teratology Information Specialists

OTIS National Office
5034A Thoroughbred Lane
Brentwood, TN 37027