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  - Voluntary Indigenous Self-Identification Form
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About
Contact
Indigenous Health
- Indigenous Self Identification
  - Voluntary Indigenous Self-Identification Form
Join Our Team
Newsroom
Patients
Programs & Services
Staff
Test 1
Visitors

Prenatal Clinic Intake Form

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Programs & Services
Women & Children’s Health Program
Prenatal Care Clinic
Prenatal Clinic Intake Form

Sault Area Hospital Prenatal Care Clinic - Referral

Referral Type(Required)

Practitioner Referral

Self Referral

Intake Date(Required)

DD slash MM slash YYYY

Patient Name(Required)

First Last

Preferred Pronouns(Required)

Partner's Name

First Last

Do you require an interpreter during your appointments?

Yes

No

Interpreter Language Required

Please, provide us with the language required. We will do our best to accommodate your needs.

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone(Required)

Type(Required)

Email

Date of Birth(Required)

DD slash MM slash YYYY

Age

Health Card Number(Required)

Expiry Date(Required)

DD slash MM slash YYYY

Insurance Provider(Required)

Other Insurance Provider

Please, provide the name of your insurance provider if not listed.

Weight

Unit:

lbs

kgs

Height

Unit

in

cm

BMI

Are you a smoker?

Yes

No

First day of your last menstrual cycle:(Required)

DD slash MM slash YYYY

Primary Care Provider(Required)

Additional Information

First Pregnancy?

Yes

No

Number of Children

Year of last birth

DD slash MM slash YYYY

Gestation in Weeks

Previous Obstetrician

C Section?

Yes

No

Any complications?

If you have had a miscarriage please, the number of miscarriages and the year.

Notes: please share any medical information including medical concerns, medications, etc.

To be completed by provider

eFTS Test

Accepted

Declined

Date

DD slash MM slash YYYY

Status

Has been ordered

Spoke to:

First Last

Panorama Test

Accepted

Declined

Date

DD slash MM slash YYYY

Status

Has been ordered

Spoke to:

First Last

Verbal consent given by client to obtain past Labour and Delivery/Operative Records:

Accept

Decline

N/A

Date

DD slash MM slash YYYY

Date of first appointment:

DD slash MM slash YYYY

Date of Ultrasound:

DD slash MM slash YYYY

8wk Ultrasound booked

Yes

No

Date - 8wk Ultrasound

DD slash MM slash YYYY

Estimated Date of Delivery [EDD]

DD slash MM slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

About
Contact
Indigenous Health
- Indigenous Self Identification
  - Voluntary Indigenous Self-Identification Form
Join Our Team
Newsroom
Patients
Programs & Services
Staff
Test 1
Visitors

Help make outstanding care possible

Sault Area Hospital

Contact Us 750 Great Northern Road
Sault Ste. Marie, ON P6B 0A8

Connect With Us

We acknowledge that Sault Area Hospital is situated upon the traditional territory of the Anishnaabeg, specifically Garden River First Nation and Batchewana First Nation, as well as the Métis People. This land, Baawaating, is the historic meeting place for Indigenous people across North America. This territory is included in the Robinson Huron Treaty of 1850. We say miigwetch to all Indigenous and Métis partners for sharing this land, and we recognize their enduring presence.

About
Contact
Indigenous Health
- Indigenous Self Identification
  - Voluntary Indigenous Self-Identification Form
Join Our Team
Newsroom
Patients
Programs & Services
Staff
Test 1
Visitors

© Copyright 2025, Sault Area Hospital

Sault Area Hospital | www.sah.on.ca | 750 Great Northern Road Sault Ste Marie, ON P6B 0A8 | (705) 759-3434

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Holiday Hours

Dec 20^th-23^rd 9:00 AM-5:00 PM

Dec 24^th Closed

Dec 27^th Closed

Dec 28^th-31^st 9:00 AM-5:00 PM

Jan 3^rd Closed

Jan 4^th-7^th 9:00 AM-5:00 PM

Happy Holidays!