High-Risk Pregnancy Notification Form
             

Complete this worksheet for any pregnant mother who is newly diagnosed or known to be living with an HIV diagnosis.


Date form completed(MM/DD/YYYY)://
Reporting Facility Name:
Reporting Facility Address:
 City:
State:
 Zip Code:
Person Completing Form:
Reporting Phone Number:

 Email Address:


Physician's Name:

Intended Delivery Facility:
Mother's First Name:
 Mother's Last Name:
Mother's Date of Birth:
// 		Mother's Medical Record #:
Estimated Due Date:
//
Was Mother Prescribed Antiretroviral Medication? Yes No Unknown
Referred to Infections Disease Specialist/Perinatologist: Yes No Unknown
Additional Comments:



For any questions related to this form, please contact Crystal Fuller at Crystal.Fuller@dph.ga.gov

              
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Date Prescribed:
// 		Medication Prescribed:
Referred Facility Name:
 Referred Physician's Name:
SendSS System Message:
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SendSS System Message:
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