Refer a Patient Helping You Educate Your Pregnant and Breastfeeding Patient Please provide us with the following information so we can contact your patient. "*" indicates required fields I am referring my patient for:Please select oneExposure counseling / informationStudy participationBoth exposure information & study participationBy 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 PhoneWhat is the patient's time zone?Please select oneAlaska (Anchorage)Atlantic (San Juan)Central (Houston)Eastern (New York)Hawaii (Honolulu)Mountain (Denver)Pacific (Los Angeles)Samoa (Apia)Patient's Language English Spanish French Other Referring Provider’s Postal Code* Referring Provider’s ZIP Code* NOTE, MotherToBaby counseling services are available only for residents of the United States and its territories.Patient’s Status: Currently Pregnant Planning a Pregnancy Breastfeeding Is the patient currently taking any prescription medications? Yes No Please list medicationsHow old is the patient's baby?Please select one0-3 months4-6 months7-12 months12 months or olderPatient's location City ZIP Code If Pregnant, Estimated Due Date: Month Day Year Does the patient have any of the following medical conditions (check all that apply): Asthma Atopic Dermatitis Coronavirus (COVID-19) Functional Constipation Lupus Multiple Sclerosis Psoriasis Psoriatic Arthritis 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 I am a:Please select oneHealthcare providerMotherToBaby counselorSelect MTB LocationPlease select oneMotherToBaby ArizonaMotherToBaby CaliforniaMotherToBaby ConnecticutMotherToBaby FloridaMotherToBaby GeorgiaMotherToBaby NebraskaMotherToBaby New YorkMotherToBaby North CarolinaMotherToBaby North TexasMotherToBaby Texas TIPSMotherToBaby UR MedicineMotherToBaby UtahCentre IMAGe: Info-Medicaments en Allaitement et GrossesseYour Name* Your Phone NumberYour Email* How did you hear about us?Please select oneGoogle/Internet SearchColleague/Fellow Health ProviderMotherToBaby CounselorNon-profit Organization (National MS Society, Arthritis Foundation, etc.)Patient Advocacy/Support Group (MyHealthTeams, PatientsLikeMe, etc.)Professional Society/Conference (ACOG, ACR, AAD, ACG, AAN, ACNM, SMFM, Pri-Med, etc.)Pharmaceutical Company/Drug LabelSocial Media (Facebook, Twitter, etc.)Other (please specify below)How did you communicate with the MotherToBaby Counselor?Please select oneEmailIn-personLive Chat on the MotherToBaby WebsitePhoneTextSocial MediaIf known, provide the name of the MotherToBaby counselor with whom you communicated: (Optional) Select the MotherToBaby location that told you about us: (Optional)Please select oneMotherToBaby ArizonaMotherToBaby CaliforniaMotherToBaby ConnecticutMotherToBaby FloridaMotherToBaby GeorgiaMotherToBaby MassachusettsMotherToBaby NebraskaMotherToBaby New YorkMotherToBaby North CarolinaMotherToBaby North TexasMotherToBaby Texas TIPSMotherToBaby UR MedicineMotherToBaby UtahCentre IMAGe (Montreal, Quebec, Canada)UnknownComments: Patient Education Our easy-to-read Fact Sheets on exposures in pregnancy and breastfeeding are available in English and Spanish. Exlore Now