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Resources for Reproductive Health Providers

Forms and Templates

The following forms and templates are available in pdf file format for viewing. Many of the templates are also available in Microsoft Word file format, to allow providers to modify the documents for their own use.

My Pregnancy Record
Hand-carried card for pregnant women, with key patient information messages in English and Spanish. A Project of the FIMR Program of the County of Sonoma Department of Health Services. Free for Sonoma County prenatal care providers. Call 707-565-4554 to order supplies.

Perinatal HIV Counseling and Consent Form
  English (pdf) (MS Word)
  Spanish (pdf) (MS Word)
Source: Sonoma County Department of Health Services.

Annual Gynecological Visit Form (pdf) (MS Word)
This form can be used to conduct family planning and annual gynecological visits for women of all ages. It incorporates routine preconception screening and education for women of childbearing age. Prescription-sized pads of the Preconception Rx, printed in English/Spanish, are available free of charge to Sonoma County providers. Contact the Perinatal Services Coordinator at 707-565-4554.

Paternity Opportunity Program Forms
Source: California Department of Child Support Services. For more information or to order supplies, please contact the Sonoma County Department of Child Support Services.

Pregnancy Risk Information Referral (pdf)
Source: California Teratogen Information Service.

Presumptive Eligibility Forms Ordering (pdf)
Source: State of California Department of Health Services.

Prenatal Dental Referral Prescription (pdf)
Source: Sonoma County Department of Health Services.

Sonoma County Newborn Referral Form for Medi-Cal Enrollment (English) (Spanish) (pdf)
Information about Newborn Referral in Sonoma County (pdf)
Source: Sonoma County Department of Health Services.

Welcome to Prenatal Care
  English (pdf) (MS Word)
  Spanish (pdf) (MS Word)
Source: Sonoma County Department of Health Services.

Some documents on this Web Site are saved in Adobe Acrobat format. If you do not own a copy of Acrobat Reader, you may download it for free.