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Maternity Booking-In Clinic Admission Form

Hospital Booking into

*
*
Today
 
 
 

Personal Details

*
*
 
 
*
As per Medicare Card

As per Medicare Card
*
As per Medicare Card

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

 
Date of Birth*
*
 

*
 

*
 
*
 

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

 
*
Address / Town / State
 
*
 
*

If you require an interpreter, please advise which language spoken.
Do you need an Interpreter:

 
Indigenous Status for YOURSELF:*



 
Indigenous Status for father of baby:*



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

 
Which Hospital (Most Recent)
Previous Caesarean: *

 
Do you currently smoke?:*

 
*
 
*
 
Medicare Card Valid To:*
 
 
 
*
 

 
 
 

Emergency Contact Details

First Name:*
Surname:*
 
 
Relationship to Patient:*
Contact Number:*
 
Address:*
 
 
 

General Practitioner / Doctor Details

*
 
*
 
Doctor's Contact Number:*
 
 
 
 

Specialist Obstetrician / GP Obstetrician / Private Midwife Details

Provider Details
 

If available
  
 
 

Midwife Details

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


 

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


 
 
 

Hospital Insurance

Hospital Insurance Type:

 

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:

 

 

 

 
 

 

Last updated: 24 March 2021
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