UC Davis Health System
Clinical Telehealth Program Referral Guidelines
Adult and Pediatric
Genomic
Medicine
Clinical Telehealth Consultations
Genomic Medicine integrates the understanding of gene interactions and environmental factors as they contribute to human disease.
Previously the Section of Genetics, the Division of Genomic Medicine in the Department of Pediatrics at UC Davis applies this information to improve health care outcomes for both adults and children with genetic/genomic disorders through diagnostic testing, clinical care, education and research. Please see our flyer for more information on our program.
Referral Indications:
 Abnormal newborn screening
test
 Suspected metabolic or
mitochondrial disorders
 One or more birth defects
 Dysmorphic facial features
 Failure to thrive
 Hypotonia
 Developmental delay/
intellectual disability
 Autism spectrum disorder
 Genetic disorder or
chromosomal abnormality
 Early onset hearing and/or
vision loss
 Abnormal sexual maturation or
delayed puberty
 Tall or short stature not present
in other family members
 Hemihypertrophy or other
overgrowth
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Multiple café au lait macules or
other skin lesions, lipomas, etc.
Suspected connective tissue
disorders
Seizures or other neurologic
conditions
Clotting abnormalities
Personal or family history of
cardiovascular disorders
(cardiomyopathy, arrhythmia)
Close relative with unexplained
sudden death at a young age
Personal or family history of
mental illness (schizophrenia,
bipolar disorder, depression)
Family history of genetic
disorder or chromosomal
abnormality
If you are unsure whether a
diagnosis is appropriate for
telemedicine, please feel free to
contact us
Necessary Clinical Information Includes:
 Complete H&P
 Report of labs such as chromosomal studies or diagnostics i.e. CT, EEG,
etc related to clinical condition
 Hearing/Vision test
 Pertinent outside records, documentation of previous evaluation
 Current medications, allergies & drug levels
 Copy of PCP intake & evaluation & specific questions
 Relevant family/social history
 Some assurance that family understands reasons for referral
 Interpreter available at the remote site when needed
Consultants:
Katherine Rauen, M.D., Ph.D.
Kristin Herman, M.D.
Madalena Martin, M.D.
Simeon Boyd, M.D.
Genetic Counselors:
Liga Bivina, M.S., LC.G.C.
Amanda Hanson, M.S., L.C.G.C.
Nicole Mans, M.S., L.C.G.C.
Vivien Triano, M.S., L.C.G.C.
Appointment Scheduling:
New: 60 minutes (initial screening)
F/U: 30 minutes
Level of Presenter Required:
MD, NP, RN, LVN
Note: Consistency of presenter for
new and follow-up patient
appointments is important
Video Equipment Required:
Videoconferencing unit
Other Equipment Required:
1. Ruler in centimeters
The following information must be
received prior to scheduling an
appointment:
1. Telehealth Referral Request Form
2. New Patient Questionnaire (new
patients only)
3. “Necessary Clinical Information”
The following must be received before
the consult begins:
1. Signed UCDHS Acknowledgement of
Receipt: Notice of Privacy Practices
form (new patients only)
2. Documented verbal consent from
patient for participation in telehealth
consultation
UCDHS Clinical Telehealth Program
Toll Free: (877) 430-5332
Referral Fax: (866) 622-5944
http://healthsystem.ucdavis.edu/cht/clinic/