PUBLIC HEALTH & SOCIAL SERVICES
                                                                                                                                                                                                                                                                                                                                                                                                                 

Fetal Infant Mortality Review Referral Form

If you are the parent or caregiver who has experienced fetal or infant loss and would like to schedule a time to share your story with one of our staff, please fill out the information below.

Please, do not disclose any personal health information in this form

Relationship *
 
412 Lilly Rd. N.E., Olympia, Washington 98506-5132
(360) 867-2500  PHSS_MCH@co.thurtson.wa.us FAX (833) 499-1806  TDD (360) 867-2603 TDD (800) 658-6384
www.thurstoncountywa.gov/phss