Sault Area Hospital Prenatal Care Clinic - Referral

Referral Type(Required)
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Patient Name(Required)
Partner's Name
Do you require an interpreter during your appointments?
Please, provide us with the language required. We will do our best to accommodate your needs.
Address(Required)
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Please, provide the name of your insurance provider if not listed.
Unit:
Unit
Are you a smoker?
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Additional Information

First Pregnancy?
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C Section?

To be completed by provider

eFTS Test
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Status
Spoke to:
Panorama Test
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Status
Spoke to:
Verbal consent given by client to obtain past Labour and Delivery/Operative Records:
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DD slash MM slash YYYY
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8wk Ultrasound booked
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This field is for validation purposes and should be left unchanged.