Prenatal Appointment Swab Test Log Form
Use this form to log and track prenatal appointment swab test visits. Please complete all fields accurately for each visit.
Appointment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Reference Code
*
Clinic or Location
*
Provider Name
*
Type of Swab Test
*
Please Select
Group B Strep
Chlamydia
Gonorrhea
Other
Reason for Test
*
Please Select
Routine Screening
Symptoms Present
Follow-up
Other
Sample Collection Method
*
Please Select
Self-Collected
Provider-Collected
Test Result
*
Please Select
Pending
Negative
Positive
Inconclusive
Follow-up Required?
*
Yes
No
Staff Initials
*
Additional Notes
Submit Log Entry
Should be Empty: