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CTIS Pregnancy Risk Information Line
(800) 532-3749

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Email a counselor

The following information will help our counselors better answer your question. Your privacy is very important to us, any information regarding your identity will not be shared with anyone other than the person responding to your inquiry.

Who referred you to our website?

Please enter the name of the adoption agency

Please enter the doctor's name

Please enter the name of the genetic counselor

Please enter the hospital name

Please select from below
Advice Nurse
OB Clinic
Primary doctor/nurse
Book, brochure or other written material

Please enter the name of the clinic

Please enter the name of the clinic or PA

Please enter the clinic and city

Please enter the WIC clinic location that referred you.

What website referred you?

First Name

Home Zip Code*

How would you like us to contact you?
email
telephone

Email*

Phone - (xxx) xxx-xxxx*

Best time to be reached during business hours

Are you
currently pregnant
planning a pregnancy
breastfeeding
adopting
healthcare provider

First day of your last menstrual period

Your date of birth

Your date of birth

Race/Ethnicity
white
black
Asian/Pacific Islander
Native American
Hispanic
other

Race/Ethnicity
white
black
Asian/Pacific Islander
Native American
Hispanic
other

Race/Ethnicity
white
black
Asian/Pacific Islander
Native American
Hispanic
other

Question

Question

Question

Question

Question

Are you currently taking (check all that apply)
folic acid
multivitamin
prenatal vitamin
none

Are you currently taking (check all that apply)
foic acid
multivitamin
prentatal vitamin
none

Women or healthcare professionals may have a similar question. Can we post your question and our response on the Q&A section of our website. The question would be posted with your first name only.
yes
no

Other individuals may have a question similar to yours. Can we post your question and our response on the Q&A section of our website? The question would be posted with your first name only.
yes
no

Other women may have a question similar to yours. Can we post your question and our response on the Q&A section of our website. The question would be posted with your first name only.
yes
no

Other individuals may have a question similar to yours. May we post your question and our response on the Q&A section of our website? The question will be posted with your first name only.
yes
no

Other women may have a question similar to yours. Can we post your question and our response on the Q&A section of our website? The question will be posted with your first name only.
yes
no

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