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

First Name *

Last Name *

Phone Number *

Primary Email Address *

Best Contact Method *

Any other comments or important considerations:

412 Lilly Rd. N.E., Olympia, Washington 98506-5132

(360) 867-2500 PHSS_MCH@co.thurtson.wa.us FAX (833) 499-1806 TTY/WA Relay 711