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.
Did You Know?
Eliminated the requirement for written consent for an HIV test eliminated
Plans and health insurers to provide coverage for testing for HIV in medical care settings
Perinatal HIV Counseling: HIV Testing is a Routine Part of Prenatal Care
English pdf | MS Word
Spanish pdf | MS Word
Source: Sonoma County Department of Health Services.
Annual Gynecological Visit Form (pdf)
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 (MS Word document)
For more information about the Medi-Cal PE program, please visit the Presumptive Eligibility for Pregnant Women website.
Prenatal Dental Referral Prescription (pdf)
Source: Sonoma County Department of Health Services.
Information about Newborn Referral in Sonoma County (pdf)
Source: Sonoma County Department of Health Services.
Sonoma County Newborn Referral Form for Medi-Cal Enrollment English | Spanish (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.
For more information, please contact:
Maternal, Child, Adolescent Health
625 5th Street
Santa Rosa, CA 95404
Phone: 707-565-4552
Toll Free: 800-427-8982