Maternity Booking-In Clinic Admission Form

Hospital Booking into

Hospital:*

Due Date:*

Today

Personal Details

Title:*

Sex:*

First Name:*

As per Medicare Card

Middle Name:

As per Medicare Card

Last Name:*

As per Medicare Card

Former Names:

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

Religion:

Date of Birth*
Day:*

Month:*

Year:*

Mobile Number:*

Home Number:

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

Yes
No

Email:*

Are you interested in upcoming Pregnancy and Parenting classes:*

Yes
No

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

Yes
No

Residential Address:*

Address / Town / State

Postcode:*

Indigenous Status for YOURSELF:*

Aboriginal
Torres Strait Islander
Both
Neither Aboriginal or Torres Strait Islander

Indigenous Status for father of baby:*

Aboriginal
Torres Strait Islander
Both
Neither Aboriginal or Torres Strait Islander

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

Yes
No

Which Hospital (Most Recent)

Previous Caesarean: *

Yes
No

Do you currently smoke?:*

Yes
No

Medicare Number:*

Position on Card :*

Medicare Card Valid To:*

Marital Status:*

Occupation:

Emergency Contact Details

First Name:*

Surname:*

Relationship to Patient:*

Contact Number:*

Address:*

General Practitioner / Doctor Details

Doctors Name:*

Medical Practice:*

Doctor's Contact Number:*

Specialist Obstetrician / GP Obstetrician / Private Midwife Details

Provider Details

Pathology & Ultrasound Results:

If available

Midwife Details

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

Yes
No

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

Yes
No

Hospital Insurance

Hospital Insurance Type:*

Full Cover - Private Patient
No 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:

Yes
No

Name of Health Fund:

Name and DOB of Contributor:

Membership Number:

Hospital Booking into
Hospital:*		Due Date:* Today
Personal Details
Title:*	Sex:*
First Name:* As per Medicare Card	Middle Name: As per Medicare Card	Last Name:* As per Medicare Card
Former Names: Maiden Name (Name you were born with) and Previous name/s		Religion:
Date of Birth* Day:*	Month:*	Year:*
Mobile Number:*	Home Number:
Do you consent to receiving text messages to your preferred phone number for clinic appointments and updates:* Yes No
Email:*
Are you interested in upcoming Pregnancy and Parenting classes:* Yes No
Do you consent to receiving emails about upcoming Pregnancy and Parenting classes:* Yes No
Do you consent to receiving emails with information on Healthy living and pregnancy programs:* Yes No
Residential Address:* Address / Town / State		Postcode:*
Country of Birth:*	Language Spoken: If you require an interpreter, please advise which language spoken.	Do you need an Interpreter: No Yes
Indigenous Status for YOURSELF:* Aboriginal Torres Strait Islander Both Neither Aboriginal or Torres Strait Islander	Indigenous Status for father of baby:* Aboriginal Torres Strait Islander Both Neither Aboriginal or Torres Strait Islander
In the last 5 years have you been admitted or attended a Hospital in NSW? * Yes No		Which Hospital (Most Recent)
Previous Caesarean: * Yes No	Do you currently smoke?:* Yes No
Medicare Number:*		Position on Card :*
Medicare Card Valid To:*
Marital Status:*
Occupation:
Emergency Contact Details
First Name:*	Surname:*
Relationship to Patient:*	Contact Number:*
Address:*
General Practitioner / Doctor Details
Doctors Name:*	Medical Practice:*
Doctor's Contact Number:*
Specialist Obstetrician / GP Obstetrician / Private Midwife Details
Provider Details
Pathology & Ultrasound Results: If available
Midwife Details
If it is available, would you be interested in having the same Midwife for the duration of your pregnancy care:* Yes No
Would you be interested in having a student midwife be part of your pregnancy, birth and postnatal care:* Yes No
Hospital Insurance
Hospital Insurance Type:* Full Cover - Private Patient No 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: Yes No	Name of Health Fund:
Name and DOB of Contributor:		Membership Number: