Dr. Lexi (Gestational Carrier)

Client Name
Account ID
Consultations

Use this form to securely begin your consultation with Dr Lexi, powered by Ouma Health. Upon submitting this form you will receive an email to schedule an intake visit followed by your consultation.
Full Name

First NameLast Name
Patient Email Address*
Please confirm this email is accurate. Upon submitting this form, we will send an email with a link to schedule an appointment with Ouma using this email address.
Date of Birth

MonthDayYear
Phone Number*
Please enter a valid phone number.
State of Residence
Patient Intake
How would you like to submit patient intake information?

Complete the intake questions nowSubmit an external link to documents containing intake information
Patient Intake
Number of Pregnancies
Pregnancy History
Current Medication
Date of Most Recent Pap and Any History of Abnormal Pap
Chronic Medical Conditions
Past Surgeries
Current Height and Weight
Previous Surrogacy Experience
Record Collection
Link to Records
If you have a Box link to patient records for us to review, paste the URL here. Please make sure this is externally accessible beforehand.
File Upload

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Google Drive Link
Any additional information you would like us to know
Attestation

In order to provide the most accurate and thorough MFM Consultation, we ask that the following medical records are submitted at the time the referral is made:
- Prenatal records for each pregnancy, including 6-week postpartum visit, lab work, and US reports
- Labor and Delivery records for each pregnancy, including H&P, Discharge note, and lab work
- Most recent physical examination
- Recent lab work
- Most recent pap smear results
- Any medical records pertaining to medical conditions they are currently being treated for
- If you have any specific concerns addressed
We understand it is not always possible to obtain the above records for every client. In the event that records are missing, we will assume the surrogacy agency has done its due diligence in obtaining them and that they are not available. If records become available after the referral is made but before the appointment takes place, please email those directly to surrogacy@oumahealth.com. We will do our best to review these prior to the appointment.

Please note that we do not accept "Patient Portal" records and will not review them, as they frequently lack pertinent information.
By checking this box, you acknowledge that all medical records that are available for this client have been submitted.

Payment

Gestational Carrier Screening Product Image

Gestational Carrier ScreeningOuma nurse initially interviews the candidate before they meet with an Ouma Maternal-Fetal Medicine specialist to ensure ASMR guideline compliance, discuss potential pregnancy risks and management, and receive MFM clearance to proceed.

$300.00

Total

$0.00

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Consultations

Patient Intake

Patient Intake

Record Collection

Attestation

Payment Methods