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pin3006 Tower Rd. Rapid CIty, SD 57701
phone-iconLocal Phone +1 (605) 343 - 7295
phone-iconCall Toll Free +1 (866) 343 - 7295

To speed up your visit, you can fill out the forms here. We will print and have them ready for you when you arrive at the office.

PATIENT INFORMATION
Patient Legal Last Name (*)

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First Name (*)

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Middle Name

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Alternate Name You Would Prefer

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Former (maiden) Name

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Date of Birth (*)

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Social Security Number (*)

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Marital Status

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Sex (*)

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Address (*)

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City (*)

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State (*)

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Zip Code (*)

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Home Phone

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Cell Phone

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Email Address

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Employer

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Occupation

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SPOUSE INFORMATION
Spouse Name

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Spouse Social Security Number

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Spouse Date of Birth

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Spouse Occupation

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Spouse Cell Phone

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INSURANCE INFORMATION
Insurance Company Name

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Policy Holder

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Group Number

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Policy Number

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Policy Holder Date of Birth

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Relationship to Policy Holder

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HOW DID YOU HEAR ABOUT US?
Referred to Rushmore OB/Gyn by:
Another Provider
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Family (name)
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Friend (name)
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Other (name)
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MINOR PATIENT INFORMATION (UNDER 18 ONLY)
Person responsible for bill

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Social Security Number

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Date of Birth

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Address

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Home Phone

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Cell Phone

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Employer

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Work Phone

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HIPAA and PHONE MESSAGE CONSENT

We at Rushmore OB/Gyn have always treated your personal health information with a great degree of confidentiality. By law we are required to provide you with the HIPAA Notice of Privacy Practice and obtain your signature to acknowledge it was available for your review.

From time to time it may be necessary or desirable to contact patients by phone. To expedite your health care and in the interest of convenience, if you are not available to speak with us directly, we would like to leave a message whenever possible. Please understand that if you do not allow blocked calls on your phone you may not get important calls from Rushmore OB/Gyn during or after business hours. To assist us in protecting your privacy, please complete the following:

Cell Phone Number (if none skip to Home Phone) Invalid Input
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Home Phone Number (if none skip to Work Phone) Invalid Input
Leave a detailed voice message? Invalid Input –if No, can we leave a call back number? Invalid Input
Work Phone Number Invalid Input Ext Invalid Input
Leave a detailed voice message ? Invalid Input –if No, can we leave a call back number? Invalid Input
How would you like your statements from our office?
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Email Address Invalid Input
May we speak with someone else regarding your medical care ? Invalid Input


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Invalid Input Relationship: Invalid Input Phone: Invalid Input
Preferred Pharmacy Name Invalid Input Preferred Pharmacy Other Invalid Input

NARCOTIC PRESCRIBING POLICY

Thank you for choosing Rushmore OB/Gyn for your healthcare. We value your trust and will make every effort to provide you the best service possible. Narcotic abuse has become an increasingly bigger problem nationwide and puts our patients’ health, and the care we provide, at risk. With that in mind, Rushmore OB/Gyn has implemented the following policy:

  1. Our providers will evaluate you at your appointment and may prescribe narcotic medications. They will only prescribe what is necessary for your condition.
  2. Our providers do not do chronic pain contracts with our patients. If you are interested in a referral to a pain specialist please discuss this with our providers.
  3. Our providers will not refill any narcotic medications that have been lost or spilled. This is your responsibility.
  4. Narcotic requests may not always be authorized on the same day you call. Please plan ahead.
  5. Our providers will not refill narcotic medications after 4:00 pm Monday through Thursday and after 3:00 pm Friday. Please plan ahead.
  6. Our providers will not refill narcotic medications on the weekend.

MEDICAL HISTORY

Have you been to Rushmore OB/Gyn within the past three years? (*)

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INTERVAL HISTORY UPDATE

Do you have drug allergies ? Invalid Input list
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Do you have non-drug allergies ? Invalid Input list
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Do you have an allergy to latex ?
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Do you have an allergy to iodine ?
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CURRENT MEDICATIONS and/or VITAMINS
Please check here if you do not take any medications and skip this section Invalid Input
MEDICATION DOSAGE

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OPERATIONS/MAJOR HOSPITALIZATIONS SINCE LAST VISIT IN OUR OFFICE
Date Description Surgeon
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Do you have non-drug allergies ? Invalid Input list
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Do you have an allergy to latex ?
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Do you have an allergy to iodine ?
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CURRENT MEDICATIONS and/or VITAMINS
Please check here if you do not take any medications and skip this section Invalid Input
MEDICATION DOSAGE

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PREGNANCY INFORMATION
please list all pregnancies including miscarriages, abortions, and births in order of occurrence
Date of Delivery, Miscarriage or Abortion Vag/ Cesarean? Complications? Weeks Gest Hours of Labor Anes Hospital Provider Name Wt, Sex Name Living?
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(2)
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(3)
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(4)
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(5)
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(6)
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(7)
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(8)
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(9)
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(10)
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GYNECOLOGIC HISTORY
How are you preventing pregnancy? (if applicable)?
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When was your last bone density? Results?
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When was your last pap? Results?
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When was your last colonoscopy? Results?
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Any history of abnormal Paps? (list)
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Who is your Primary Care Physician?
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When was your last mammogram? Results?
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What age did you go through menopause (if applicable)?
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When was your last Hepatitis C screen? Results?
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When was your last Tdap?
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PERSONAL HISTORY
YES / NO YES / NO
Asthma
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Heart Trouble/Murmur (specify)
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Anxiety
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High Blood Pressure
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Blood Clot/DVT/Pulmonary Embolism
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Hyperthyroid Disorder
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Blood Transfusions (list)
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Hypothyroid Disorder
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Cancer (specify site)
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Irritable Bowel Syndrome
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Chronic Lung Disease
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Seizures/Convulsions/Epilepsy
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Diabetes
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Sexually Transmitted Infection (list year/type)
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Depression
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Cerebrovascular Accident (Stroke)
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Glaucoma
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Other Illnesses (list)
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OPERATIONS/MAJOR HOSPITALIZATIONS
Date Description Surgeon

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FAMILY HISTORY
Please check here if you were adopted and skip this section
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YES Relative (ex. maternal aunt) YES Relative (ex. maternal aunt)
Coronary Artery Disease
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Endometrial Cancer
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Thyroid Disorder
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Colon Cancer
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Deep Vein Thrombosis
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Ovarian Cancer
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High Blood Pressure
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Cerebrovascular Accident (stroke)
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Myocardial Infarction
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Transient Ischemic Attack (mini-stroke)
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Breast Cancer
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Diabetes
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      Other (list)
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Is your mother currently living ? Invalid Input (cause of death) Invalid Input
Is your father currently living? Invalid Input (cause of death) Invalid Input
Are your siblings currently living? Invalid Input (cause of death) Invalid Input
Do you currently smoke? Invalid Input packs per day Invalid Input years Invalid Input
Did you previously smoke? Invalid Input year discontinued Invalid Input
Do you currently use alcohol? Invalid Input drinks per week Invalid Input
Do you or have you currently use illicit drugs? Invalid Input list Invalid Input

OBSTETRICAL CARE

Are you currently pregnant? (*)

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Father of the Baby’s Name (if different) Invalid Input Phone Number Invalid Input
Emergency Contact Name (if different) Invalid Input Phone Number Invalid Input
Obstetrical Provider Preference Invalid Input
How certain are you of your last period? Invalid Input
First day of your last menstrual period Invalid Input
Was your last menstrual period normal in amount or duration? Invalid Input
How many days apart are your menstrual cycles? Invalid Input
Were you on birth control pills when you conceived? Invalid Input
What age were you at first menstrual period? Invalid Input
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What race are you? Invalid Input
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PAST MEDICAL HISTORY FOR YOU

YES / NO Details if yes
Diabetes Invalid Input Invalid Input
Hypertension Invalid Input Invalid Input
Heart Disease Invalid Input Invalid Input
Autoimmune Disorder Invalid Input Invalid Input
Kidney Disease/ UTI’s Invalid Input Invalid Input
Neurologic Disorder/Epilepsy Invalid Input Invalid Input
Psychiatric Disorders Invalid Input Invalid Input
Depression/Postpartum Depression Invalid Input Invalid Input
Hepatitis/Liver Disease Invalid Input Invalid Input
Varicosities/phlebitis Invalid Input Invalid Input
Thyroid Dysfunction Invalid Input Invalid Input
Trauma/Violence Invalid Input Invalid Input
History of Blood Transfusion Invalid Input Invalid Input
Tobacco Use Since Positive Pregnancy Test Invalid Input Invalid Input
Alcohol Use Since Positive Pregnancy Test Invalid Input Invalid Input
History of Illicit Drug Use? Invalid Input Invalid Input
Illicit Drug Use Since Positive Pregnancy Test Invalid Input Invalid Input
D (Rh) Sensitized Previously Invalid Input Invalid Input
Rh negative (blood type is O-, A-, B-, and AB-) Invalid Input Invalid Input
Pulmonary Disorders (asthma) Invalid Input Invalid Input
Seasonal Allergies Invalid Input Invalid Input
Drug/Latex Allergy Invalid Input Invalid Input
Breast Problems Invalid Input Invalid Input
Gynecologic Surgery Invalid Input Invalid Input
Operations/Hospitalizations Invalid Input Invalid Input
Anesthesia Complications Invalid Input Invalid Input
Uterine anomaly Invalid Input Invalid Input
IVF/ART Assistance for Pregnancy Invalid Input Invalid Input
Relevant Family History Invalid Input Invalid Input
Other Invalid Input Invalid Input

RISK ASSESSMENT

Do you live with someone with TB or that has been exposed to TB? Invalid Input Invalid Input
Do you or your partner have a history of genital herpes? Invalid Input Invalid Input
Do you have hepatitis B or C? Invalid Input Invalid Input
Do you have a history of Gonorrhea? Invalid Input Invalid Input
Do you have a history of Chlamydia? Invalid Input Invalid Input
Do you have a history of HIV? Invalid Input Invalid Input
Do you have a history of Syphilis? Invalid Input Invalid Input
Do you have MRSA now or have you in the past? Invalid Input Invalid Input
Other? Invalid Input Invalid Input
Did you have chicken pox as a child?


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Did you receive the chicken pox vaccine?


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Have you or your partner traveled to a known Zika epidemic area within the last 6 Months
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GENETIC SCREENING

These questions pertain to you (the patient), the baby's father, or anyone in either family.
YES / NO Details if yes
You will be 35 or older when you deliver? Invalid Input Invalid Input
Thalassemia? Invalid Input Invalid Input
Neural tube defects (meningomyelocele, spina bifida, or anencephaly)? Invalid Input Invalid Input
Congenital heart defect? Invalid Input Invalid Input
Down Syndrome? Invalid Input Invalid Input
Tay-Sachs? Invalid Input Invalid Input
Canavan Disease? Invalid Input Invalid Input
Familial Dysautonomia? Invalid Input Invalid Input
Sickle Cell Disease or Trait (African American)? Invalid Input Invalid Input
Hemophilia or other blood disorders? Invalid Input Invalid Input
Muscular Dystrophy? Invalid Input Invalid Input
Cystic Fibrosis? Invalid Input Invalid Input
Huntington’s Chorea? Invalid Input Invalid Input
Developmental Disability Invalid Input Invalid Input
Other inherited genetic or chromosomal disorders? Invalid Input Invalid Input
Maternal metabolic disorder (type 1 diabetes, PKU)? Invalid Input Invalid Input
You or the baby’s father had a child with birth defects not listed above? Invalid Input Invalid Input
Recurrent pregnancy loss, or stillbirth? Invalid Input Invalid Input
Medications you’ve taken since your last menstrual period? Invalid Input Invalid Input
Other? Invalid Input Invalid Input
BIRTH PLANNING
Name of the pediatrician you are planning to take care of the baby after birth Invalid Input
Will you accept a blood transfusion if medically necessary? Invalid Input
Are you planning to breast or bottle feed? Invalid Input
Are you planning circumcision if you have a boy? Invalid Input
Planned anesthesia? Invalid Input

Routine Obstetrical Care Consent Form

The providers at Rushmore OB/Gyn want the best care for you and your baby.  There are certain minimum requirements that we feel are essential for a pregnancy and delivery.  If you are not comfortable with these, our office may not be a good fit for you.  Our minimum requirements are:

  • Rhogam for Rh negative mothers
  • IV access with a minimum of a saline lock upon admission to labor and delivery
  • A minimum of intermittent monitoring of mom and baby during labor, continuous monitoring may be deemed necessary by your provider depending on your particular situation
  • The following bloodwork described in detail below:

Routine Labs at Your First Visit

The lab tech will draw your blood and collect your urine for the following tests. Other tests may be recommended by your provider based on your personal or family medical history.

  • Blood Type and Rh Factor – We check your blood type with each pregnancy in the rare case that you would need a blood transfusion. The Rh factor for your blood type is either positive or negative. If you have a negative Rh factor, you will need an immunization called RhoGAM to prevent complications with your pregnancy.
  • CBC – Complete blood count to look for anemia (not enough red blood cells) and other blood problems such as infections or not enough platelets (cells that help your blood clot).
  • Hepatitis B – We check to see if you have been exposed to this virus, which causes liver disease. If you have hepatitis B, your baby can be treated after birth to prevent them from developing hepatitis.
  • HIV – We check to see if you have been exposed to this virus, which harms your immune system. The CDC recommends all pregnant women be tested for the HIV virus.
  • Rubella – We check to see if you are immune to rubella (German measles). If you are not immune, you will be offered a rubella immunization after you have your baby.
  • Syphilis – This is a sexually transmitted infection that can be passed to the baby. It can be treated with antibiotics if caught early to prevent your baby from catching it.
  • Urinalysis – We screen your urine to check for infections. Urinary infections are very common during pregnancy, and do not always cause symptoms. We do not routinely do pregnancy tests on your urine sample.

Routine Labs Done with Your Physical Exam

Pap Smear – This test is done during pregnancy to screen for cervical cancer. If you have had one done recently, you may not need this done. You can discuss if you need one with your provider.

  • STI Screen – This test looks for Chlamydia and Gonorrhea, two common sexually transmitted infections that can be passed to the baby. They are treated with antibiotics.

Routine Labs Done around 28 Weeks of Pregnancy

CBC – Complete blood count to look for anemia and other conditions such as low platelets.

  • Gestational Diabetes Screen (Glucola) – We screen for diabetes caused by pregnancy (gestational diabetes). This consists of a sugar drink followed by a blood draw done 1 hour later. Some women will also have this test done early in the pregnancy if you have risk factors for diabetes, such as having gestational diabetes in a previous pregnancy, you are overweight, or you have delivered a large baby with a previous pregnancy.
  • Syphilis – This is a sexually transmitted infection that can be passed to the baby. It can be treated with antibiotics if caught early to prevent your baby from catching it.

Routine Labs done around 36 Weeks of Pregnancy

  • Group B Strep (GBS) Screen – We check to see if you are a carrier of the group B strep bacteria in your vagina. 30% of women carry this bacteria, which is not harmful to you, but can cause the baby to become very ill if they catch it during delivery. If you are a carrier, you will need antibiotics when you are in labor.

I have read and understand the above information. I am aware that these tests are routinely done on all pregnant women with each pregnancy. I have had all my questions answered regarding these tests. I understand these tests help my providers give me appropriate medical care during my pregnancy. Certain test results may, if positive, be reported to the Department of Health in my state as required by law. I choose to have these tests performed.

Optional Screenings Available

Cystic Fibrosis Screening

Cystic fibrosis is a genetic disease that is passed from parents to children. It primarily affects the lungs and digestive system. For a baby to have cystic fibrosis (CF), both the mother and father need to carry the gene for CF. We can test you for the gene. This is done with a blood test that can be done at any time during the pregnancy. If you have the gene, we can then test the father of the baby. If both of you have the gene, your baby has a 1 in 4 (25%) chance of having CF. (Please be aware that this is an expensive test and it is recommended you check your insurance coverage.  Even if insurance does decline coverage you can choose to have the test and pay for it.)

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Noninvasive Prenatal Testing

The Noninvasive Prenatal test (NIPT) is a non-invasive test for Down Syndrome (Trisomy 21), Edwards Syndrome (Trisomy 18), Patau Syndrome (Trisomy 13), and other Sex Chromosome Conditions (Klinefelter Syndrome, Turner Syndrome).  These syndromes are caused when there is an unexpected number (normal is two) of a particular chromosome.  The test measures the amount of fetal chromosomes in the maternal blood, giving a risk for the above syndromes.  The testing can be completed at any time after 9 weeks gestation and is a blood draw.  This test is available for all pregnancies but is most recommended for high-risk obstetrical patients.  (Please be aware that this is an expensive test and it is recommended you check your insurance coverage.  Even if insurance does decline coverage you can choose to have the test and pay for it.)

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First Trimester Screening (Nuchal Translucency Screen or NT Screen)

The NT screen is a combination of blood tests and an ultrasound that is done to screen for Down Syndrome, or Trisomy 21, where the baby has 3 copies of the 21st chromosome. This results in issues such as mental retardation and defects with the baby’s organs such as the heart. It also can detect Trisomy 18. This screening is done between 11 and 14 weeks of pregnancy. It is more accurate at detecting problems than the Quad Screen and can be done earlier in pregnancy. We do not perform this screening in our office, but we can refer you to a number of other facilities where you can have this screening done. If the test comes back abnormal, you will be offered further testing. (Please be aware that this is an expensive test and it is recommended you check your insurance coverage. Even if insurance does decline coverage you can choose to have the test and pay for it.)

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Second Trimester Screening (Quad Screen)

The Quad Screen is a blood test that is done on the mother to look for certain birth defects in the baby between 16 0/7 and 19 weeks optimally of pregnancy. The most common problem this test can detect is Down Syndrome. Another problem this test can detect is spina bifida, where the baby’s spine closes incorrectly. This test can have false positives, where the test results are abnormal, but the baby is normal. The test can also have false negatives, where the test results are normal, but the baby is born with a defect that the test will usually detect. If the test comes back abnormal, you will be offered further testing.

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Research Opportunity

Avera Research Institute, Center for Pediatrics and Community Research has invited pregnant patients to be involved in a research study. The study is called ECHO: Environmental Influences on Child Health Outcomes, and is being supported by the National Institute of Health. They are hoping to understand the effects of a broad range of early environmental influences on child health and development. Avera Research Institute would like permission to contact you to determine if you could be involved in their research study.

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SIGNATURE

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Rushmore OB/Gyn. I understand that I am financially responsible for any balance after insurance payments, or any balance not covered by my insurance policy. I also authorize Rushmore Obstetrics & Gynecology to release any information required to process my claims. I fully understand that Rushmore Obstetrics & Gynecology, its successor or assignees (including attorneys and collection agencies) may use the information provided upon this form for the purposes of outstanding debt collection. By signing this form, I consent to such use of the information provided herein.

Furthermore, I authorize Rushmore Obstetrics & Gynecology to send my medical records from Rushmore Obstetrics & Gynecology to any referring physicians for continuity of care.

I acknowledge that I have read and understand the Narcotic Prescribing Policy.

I acknowledge that I have read and understand the HIPAA and Phone Message Consent Form.

Patient Signature:
Please use your mouse to sign below.

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