Refer a Patient to Our Studies Your Referral Improves Medication Safety Information in Pregnancy Please provide us with the following information so we can contact your patient. "*" indicates required fields 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 PhoneWhat is the patient's time zone?Alaska (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* 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?0-3 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:Select OneHealthcare providerMotherToBaby counselorSelect MTB LocationSelect OneMotherToBaby ArizonaMotherToBaby CaliforniaMotherToBaby ConnecticutMotherToBaby FloridaMotherToBaby GeorgiaMotherToBaby MassachusettsMotherToBaby 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?Google/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?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)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