SNSWLHD - Maternity Booking-In Clinic Admission Form

Maternity Booking-In Clinic Admission Form

Hospital Booking into

Hospital *

Due Date *

Personal Details

Title *

Sex *

First Name *As per Medicare Card

Middle NameAs per Medicare Card

Last Name *As per Medicare Card

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

Country of Birth *

Religion

Date of Birth *

Mobile Number *

Home NumberPlease include area code

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

Indigenous Status for father of baby: *

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

Do you currently smoke? *

YesNo

Are you an Australian Citizen *

Yes No

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: *

Specialist Obstetrician / GP Obstetrician / Private Midwife Details

Provider Details

Pathology & Ultrasound Results

Browse

(If available)

Midwife Details

If it is available, would you be interested in having the same Midwife for the duration of your pregnancy care: *

YesNo

Student Midwife Details

On top of extensive clinical placement, midwifery students are required to follow 10 women through their pregnancy, birth and postnatal period (and attend at least 6 of those 10 births) in order to graduate and enter the profession of midwifery.

This provides an invaluable experience for the student to learn, and provides the woman additional emotional, physical and educational support (and a familiar face) as they navigate pregnancy, birth and the postnatal period.

What’s involved?

Your student will attend and provide support for at least:

4 antenatal appointments/classes/screening tests;
labour + birth (if you are open to this); +
2 postnatal appointments
someone to turn to in the waiting room, before, after and between appointments for additional support

What will your student midwife do?

A source of emotional and physical support during and between appointments and labour and birth (if you want them there)
Provide you with additional resources on key topics arising during pregnancy, birth and postpartum (students are at the coalface of current research, drawing on it in their studies every day)
Be a familiar face
Advocate for your wishes or birth preferences

What does the evidence say about student midwives?

Physical outcomes
A Queensland study by Tickle et al. (2022) looked at the outcomes for women birthing with midwifery student and found:

lower rates of induction of labour
lower rates of caesarean section
higher rates of spontaneous vaginal birth
reduction in rates of smoking post 20w of pregnancy
lower rates of episiotomy for women giving birth vaginally for first time
lower pharmacological pain relief use in labour + birth
higher rates of Vaginal Birth After Caesarean
reduction in 3rd+4th degree tears for women without a known midwife

Experiences
Women who received support from midwifery students:

reported feelings of support, presence, empowerment, relationship and partnership
described the student as providing advocacy and assistance in navigating the maternity system, as a “bridge” between them and the maternity system
would recommend a midwifery student to family and friends (97.6%)

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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