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  • About
    • Our Mission
    • About Maternal Health
    • When to Seek MFM Support
    • Conditions We Treat
    • What to Expect on Your First Visit
    • Frequency of Consultations
    • Providers & Staff
  • Resources
    • Patient & Provider Forms
    • Educational Materials
    • Patient Portal Login
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Patient & Provider Forms

Patients, please download, complete, and return all relevant forms prior to your visit.

  • New Patient Form
  • Disclosure Form
  • Consent to Treat Form
  • Telemedicine Consent Form
  • Records Release Form
  • Provider Referral Form
  • Standard Blood Sugar Log
  • Cancellation Policy
Mertz MFM logo

3815 Forrestgate Drive
Winston-Salem, NC 27103

Phone: (336) 930-9600
Fax: (336) 999-7553
E-Fax: (336) 930-9930

About Us

  • Mission & Vision
  • About High-Risk Pregnancy
  • When to Seek MFM Support
  • Conditions We Treat
  • What to Expect on Your First Visit
  • Frequency of Consultations
  • Providers & Staff

Resources

  • Patient Forms
  • Educational Materials
  • Patient Portal Login
Close
SCHEDULE A CONSULTATION