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High-Risk Pregnancy Notification Form Miami-Dade County Health Department Perinatal Please send confidential fax to: 305-470-5533 Required Reporting Information (per Florida Statute: 64D-3-2026
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How to Use or Fill Out the High-Risk Pregnancy Notification Form Miami-Dade County Health Department Perinatal
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- Click ‘Get Form’ to open it in our editor.
- Begin by filling in the 'Today’s Date' field with the current date.
- Enter the 'Facility Name' where the patient is being treated.
- Provide the 'Physician Name' responsible for the patient's care.
- Input the 'Office Chart ID/File #' for tracking purposes.
- Complete the 'Gravida/Para' section to indicate pregnancy history.
- Fill in the 'Estimated Delivery Date' based on medical assessments.
- Specify the 'Hospital Name' where delivery is planned.
- Indicate if medication was prescribed by checking 'Yes' or 'No'.
- If applicable, enter the 'Date Prescribed' for any medications.
- Note whether a referral to an Infectious Disease Specialist/Perinatologist was made.
- Fill in your details as the reporter, including your name and telephone number.
- Once completed, ensure all information is accurate before submitting. Place this form in the patient’s office chart and fax it to 305-470-5533 within two weeks of diagnosis.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2012 | 4 Satisfied (33 Votes) |
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