MLHD - Maternity Booking-In Clinic Admission Form

Maternity Booking-In Clinic Admission Form

Hospital Booking into

Hospital *

Due Date *

Personal Details

Title *

Your Sex recorded at birth *

First Name *As per Medicare Card

Middle NameAs per Medicare Card

Last Name *As per Medicare Card

Preferred Name

Former NamesMaiden Name (Name you were born with) and Previous name/s

Country of Birth *

Religion

Date of Birth *

Mobile Number *

Alternate Number

Do you consent to receiving text messages to your preferred phone number for clinic appointments and updates *

YesNo

Email *

Are you interested in upcoming Pregnancy and Parenting classes *

YesNo

Do you consent to receiving emails about upcoming Pregnancy and Parenting classes: *

YesNo

Do you consent to receiving emails with information on Healthy living and pregnancy programs: *

YesNo

Residential Address: *

Street address *

City *

State *

Postcode *

Language Spoken

Do you need an Interpreter

YesNo

Indigenous Status for YOURSELF: *

AboriginalTorres Strait IslanderBothNeither Aboriginal or Torres Strait Islander

In the last 5 years have you been admitted or attended a Hospital in NSW? *

YesNo

Which Hospital (Most Recent)

Previous Caesarean: *

YesNo

Have you had a baby born before 37 weeks *

YesNo

Australian citizen *

YesNo

Do you have an Australian Medicare card *

YesNo

Medicare Number: *

Position on Card: *

Medicare Card Valid To: *

Marital Status: *

Occupation:

Emergency Contact Details

First Name: *

Last Name: *

Relationship to Patient: *

Contact Number: *

Address: *

Street address *

City *

State *

Postcode *

General Practitioner / Doctor Details

Doctors Name: *

Medical Practice: *

Doctor's Contact Number: *

Other Care Providers

Provider NameSpecialist Obstetrician / GP Obstetrician / Private Midwife Details / Doula / etc.

Provider Details

Pathology & Ultrasound Results

Browse

(If available)

Midwifery Group Practice

Midwifery Group Practice (MGP) provides you with a known midwife who cares for you during your pregnancy, your birth and postnatal (after birth) time.

If available, would you like to be part of the Midwifery Group Practice were the same small group of midwives will look after you from pregnancy to postnatal? *

YesNo

Please note that if you wish to participate in midwifery group practice in Wagga Wagga, you need to either live within 25km of Wagga Wagga Base Hospital or be willing to travel to Wagga Wagga Base Hospital to recieve your antenatal and postnatal care.

I agree *

Would you be interested in having a student midwife be part of your pregnancy, birth and postnatal care: *

YesNo

Hospital Insurance

Hospital Insurance Type: *

Full Cover - Private PatientNo Cover - Public Patient

If you choose to use your private health insurance you may be able to receive some benefits, depending on your chosen hospital.

Member of Health Fund: *

YesNo

Name of Health Fund:

Name and DOB of Contributor:

Membership Number:

Trick1

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