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Please fax to 00971 04 3096274      
Email contacts;  
Dr George Michailidis  
gmichailidis@ahdubai.com 
Mrs Angelica Gongora – Clinic Nurse  
obgyn_nurse1@ahdubai.com 
 
 
Doctor's Referral Form  
NAME 
DOB 
Contact Tel Numbers                                                                                  
CITY/COUNTRY 
 
REFERRING DOCTOR 
Referring Doctor Contact Numbers 
Referring Doctor Fax/ Email 
DATE.................................................................................................................................... 
Referral for;           DOWN'S SCREENING / MORPHOLOGY SCAN/ GROWTH SCAN/  
                                  CVS / AMNIO / OTHER (please state) 
  
Referral Details (relevant history) 
 
 
LMP                                                         EDD                                            Singleton/ Multiple pregnancy 
Do the parents need an interpreter yes / no.   If yes what language is required ?  
 
Appointment date/time; 
Appointment booked by;  
 
