I acknowledge that there are risks associated with a planned birth at home and that those risks include but are not limited to not having immediate access to, or having delayed access to, obstetric, anaesthetic and neonatal services. *

Agree

I acknowledge that if I am choosing to birth in hospital or my care is transferred to hospital my midwife will not provide clinical care during my labour and birth unless my midwife has admitting rights at the receiving hospital and has provided <12 consecutive hours of care. *

Agree

I acknowledge that the risks material to my personal circumstances and preferences been discussed with me. *

Agree

I have been given an opportunity to ask any questions that I have and to obtain the answers and advice that I need in relation to these risks in order to make an informed decision about the management of my pregnancy and the midwifery services that I need. *

Agree

I understand that any risks will be managed with my midwife in consultation with me and the collaborating health provider i.e. obstetrician or hospital, in line with relevant guidelines. *

Agree

I understand that the midwife/midwifery practice providing services to me is obliged to act within the relevant professional guidelines which may include: 1. consulting with another midwife or a medical practitioner who provides obstetric services; 2. referring me to a medical practitioner who provides obstetric services; 3. transferring my care to a medical practitioner who provides obstetric services. *

Agree

I understand that my personal and health information and/or the personal and health information of my baby may be provided to other health professionals including: another midwife; the obstetrician with whom there is a Collaborative Arrangement; my nominated general practitioner; the hospital with whom there is a Collaborative Arrangement or Care Plan; a pathology services provider; a radiology services provider; other health professionals who may be required to be involved in the care of me and/or my baby.

Agree

I understand that my personal and health information and/or the personal and health information of my baby will not be used for any other purpose without my consent apart from circumstances in which the law mandates release of the information.

Agree

I understand that the Midwife services provided to me are made under a collaborative arrangement with a Doctor/public hospital I understand that my midwife is required to follow a process to communicate a Care Plan to the back-up hospital to ensure that relevant information about my pregnancy, should transfer to hospital be required for my baby or myself. A back up midwife will be appointed to you who you will meet at approx. 36 weeks. It cannot be guaranteed that your back up midwife will have the same admitting rights in respective hospitals as your primary midwife. I understand that as required by law a second Midwife will also aim to be present at the birth of my child to provide assistance during the labour and the birth if the birth is at home. It cannot be guaranteed that the back up midwife you meet in pregnancy will be the backup midwife at your birth. *

Agree

I understand that the scheme does not cover intra-partum care (labour or birth) at home or outside a hospital that provides obstetric services and the implications of this have been explained to me. *

Agree

I acknowledge that if I am planning to birth in hospital but midwife attends my labour at home her PI insurance does not cover her for labour and birth care. *

Agree

I understand that the midwife is only insured for the ante-natal and post-natal care that will be provided to me and my baby and that she/he is not insured for the labour care or birth at home. *

Agree

I acknowledge that the financial costs of the Midwifery services described in this document are: I will pay the full fee of $8000 over the period of my care, as per the payment schedule. If care is terminated by the client a holding fee of $1000 will be invoiced along with fees worked out pro rata for care already received. If care is terminated by the midwife a refund is worked out on care not provided. I understand that my midwife will not be on call for my labour and birth if I have fees outstanding unless otherwise agreed to with my midwife. *

Agree

Name *

First Name

Last Name

Date *

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