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

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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