BIRTHCARE REGISTRATION FORM

 

Please do not complete this form until you have an LMC.

If you do not have an LMC and would like to birth at Birthcare please send us an email.

 

 

PERSONAL DETAILS

 

Your full name*

NHI number (optional) 'ABC 1234'

 

Residential address*

Your date of birth*

 

Day time phone number*

Evening phone number

 

Country of Birth*

Occupation (optional)

 

Email*

 

Ethnic Group*

Do you need an interpreter?

   

 

Special Dietary Needs / Allergies

Drug Allergies

 

 

BIRTHCARE SERVICE SELECTION

 

Please refer to Birthcare's Schedule of Charges for full pricing information as you must meet certain

criteria for our free services.

 

Are you a NZ resident?*

Birthcare Options for non NZ Residents (select all that apply)
NOTE: Birthcare only provides facilities for normal labour and Birth.

Birthcare Options for NZ Residents
NOTE: Birthcare only provides facilities for normal labour and Birth.
Room Options (conditions apply, please see our schedule of charges)


Room Options (conditions apply, please see our schedule of charges)


 

Additional Comments/Requirements (optional)

 

 

SCHEDULE OF CHARGES

I have read and agree to Birthcare's Schedule of Charges*

 

 

LEAD MATERNITY CARER

 

Lead Maternity Carer Type*

 

Name of Lead Maternity Carer*

Name of Postnatal Midwife

 

Expected delivery date*

Proposed Place of Delivery*

 

Gravida (number of pregnancies you have

had including this pregnancy)*

 

Parity (number of babies previously born)*

 

 

NEXT OF KIN OR CONTACT PERSON

 

Name*

Relationship to you

 

Their phone number*

Their evening contact number

 

Their address

 

BLOOD INFORMATION

 

Blood Group

Rhesus

Hepatitis B

 

MEDICAL HISTORY

 

Do you have any Medical history?*

 

BMI*(please ask your LMC if you do not know your BMI)

 

 

 

Please ask your LMC if Birthcare is the most appropriate place for you to birth

 

OBSTETRIC RECORD

(Based on Gravida Number entered above)

 

 

CODE OF RIGHTS

I have read the Code of Rights*

 

View our information tour of Birthcare.