Other: Other Transfer Facility: Other Birth Facility:                   (If you fail to print using the print button, please print directly from your web browser.) 2. Print a copy for your record.                     Phone: Phone: Primary Pediatric Provider: Specialty Provider: Phone: Reporting Source: Provider Information Date: Date: Date: Date: Date: Date: Referrals Made Phone #: Zip: State: City: Address: Adoptive/Foster Parent(s) Name: Phone #: MR#: DOB: Mother's Information        Diagnosis confirmed by: Status: Or EDD: Diagnosis Autopsy: If Deceased: Date of Death: MR#: MR#: Transfer Facility: Birth Status: Name(F/M/L): 1. Please review information above carefully. Birth Facility: Sex: DOB: Instructions: Name(F/M/L): Upon completion of this form... Maine Birth Defects Program ChildLINK / Maine Birth Defects Program is a partnership between Maine CDC and the University of Maine. Comments For questions regarding this form or the Birth Defects Program in general, please contact Diane Haberman at 207-287-8424.
If you encounter any technical problems while submitting this form, please contact Cecilia Cobo-Lewis at 207-581-2010.
If this form is a correction of a previous data entry error, please check this box. Address: City: State: 3. Please submit form to ChildLINK/Maine Birth Defects Program by clicking the submit button below ONCE! Zip: Date of Discharge/Transfer: Confidential Medical Report Child's Information   Other 3: Other 1: Other 2:   CARDIOVASCULAR EYE GASTRONINTESTINAL OTHER   GENITOURINARY    OROFACIAL CHROMOSOMAL MUSCULOSKELETAL EAR CENTRAL NERVOUS SYSTEM