adressographe - Grossesse Estrie.

NAME :
ADDRESS : TOWN :
TELEPHONE 1 : ADRESSOGRAPHE
POSTAL CODE: TELEPHONE 2 : DATE OF BIRTH : NEED AN INTERPRETER : NO
YES
LANGUAGE :
WHY COMPLETE A NOTICE OF PREGNANCY
• To offer you the best services in your area, according to your needs
• To facilitate access to a family doctor, specialist or midwife for prenatal care during your pregnancy
• To make sure you will have access to a healthcare professional in the first ten weeks of your pregnancy
DIRECTIONS
• If you don’t have a family doctor or other healthcare professional for your prenatal care, complete sections 1 and 3.
• If you have a family doctor or other healthcare professional for your prenatal care: contact the clinic for an appointment.
Once that is done, complete sections 1 and 3.
• If your family doctor does not do prenatal care, the medical clinic will direct you to other professionals. Call the one you choose
for an appointment. Once that is done, complete sections 1 and 3. (In case no appointment is available for your prenatal care, then complete sections 1 and 3 of the notice of pregnancy).
SECTION 1
INFORMATION ABOUT YOUR PREGNANCY
Date of first day of last menstruations : ______/____/____
aaaa mm jj
doesn’t know
Number of weeks of pregnancy :
SECTION 2
COMPLETE THE FOLLOWING INFORMATION
Name of healthcare professional for your prenatal care ( doctor, gynaecologist or midwife) : Place where the care will be done : Is the initial appointment for your exam before the first 10 weeks of pregnancy?
Yes
SECTION 3
No
CONSENT FOR PASSING ON INFORMATION
I agree that these informations be passed on to the CSSS of my area.
I agree : Signature of the pregnant woman
Date : Notice of pregnancy sent by : SEE ON THE BACK FOR CSSS COORDINATES
➜
WHO CAN COMPLETE THE NOTICE OF PREGNANCY AND HOW TO PASS IT ON
For the pregnant woman
Choose between three possibilities
I. I.Complete this formulary and fax/or mail it to the CSSS
OR
II Complete the interactive formulary available on line at the following address :
www.GrossesseEstrie.ca.
OU
III. Call your CSSS to complete a notice of pregnancy (see coordinates below)
For the healthcare professional1
I. Ask the pregnant woman if a notice of pregnancy has been completed
(in the presence of the pregnant woman)
II If the answer is no, have the woman complete the notice of pregnancy and either fax it or mail
it to your CSSS
III. Consent must be obtained prior to sending it to the CSSS
CSSS
CSSS DU GRANIT
CSSS DU HAUTST-FRANÇOIS
CSSS-IUGS
(SHERBROOKE)
CSSS DE
MEMPHRÉMAGOG
CSSS DE LA MRC-DECOATICOOK
CSSS DES SOURCES
CSSS DU VAL-STFRANCOIS
COORDINATES
CITY AREA/TOWN
3569, Laval Street
Lac-Mégantic (Québec)
G6B 1A5
819 583-2572, # 2503
819 583-5364
Audet
Frontenac
Lac-Drolet
Lac-Mégantic
Marston
Milan
Saint-RobertBellarmin
Val-Racine
Notre-Damedes-Bois
Stratford
Courcelles
Lambton
Saint-Romain
Nantes
Saint-Sébastien
Stornoway
Piopolis
Saint-Ludger
700, Craig Nord Street
Cookshire (Québec) J0B 1M0
819 821-4000
819 875-1808
Ascot Corner
Chartierville
Saint-Isidorede-Clifton
La Patrie
Lingwick
CookshireEaton
Hampden
Newport
Dudswell
East Angus
Scotstown
Weedon
Westbury Bury
1200 King Est
Sherbrooke (Québec) J1G 1E4
819 780-2220, # 80104
819 565-1887
Deauville
JacquesCartier
Rock Forest
Mont-Bellevue
Lennoxville
Brompton
Fleurimont
Saint-Élie
d’Orford
50, St-Patrice Est Street
Magog (Québec) J1X 3X3
819 843-2572 # 2801
819 868-3248
Orford
Potton
Hatley
Magog
Hatley
Stanstead
Stanstead
Stukely-Sud
Ogden
Austin
Eastman
Sainte-Catherinede-Hatley
Ayer’s Cliff
Bolton-Est
North Hatley
Saint-Étiennede- Bolton
Saint-Benoît-duLac
138, Jeanne-Mance Street
Coaticook (Québec) J1A 1W3
819 849-4876, # 57316
819 849-6734
BarnstonOuest
Coaticook
Compton
Waterville
Dixville
East Hereford
Martinville
Saint-Malo
Stanstead-Est
SainteEdwidge-deClifton
Saint-Venantde-Paquette
SaintHerménégilde
475, 3rd Avenue
Asbestos (Québec) J1T 1X6
819 879-7158, # 428
819 879-7345
Asbestos
Danville
Saint-Adrien
Saint-Camille
Wotton
Saint-Georges- Saint-Josephde-Windsor
de-Ham-Sud
23, Ambroise-Dearden Street
Windsor (Québec) J1S 1G8
819 542-2777, # 55268
819 845-2084
Bonsecours
Kingsbury
Lawrenceville
Maricourt
Melbourne
Racine
Sainte-Annede-la-Rochelle
Saint-Denisde-Brompton
Stoke
Val-Joli
Windsor
Saint-FrançoisXavier-deBrompton
Cleveland
Richmond
Saint-Claude
Ulverton
Valcourt
Health professionals: Doctor, obstetrician, midwife, nurse, etc. The healthcare professional may delegate to an administrative agent to complete and submit the Notice of
pregnancy CSSS territory of the pregnant woman. In the last line of the form, enter the name of the administrative agent and add the name of the healthcare professional.
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