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.

 

Which Facility would you like to register with?*

 

PERSONAL DETAILS

 

Your first name*

Your surname*

 

NHI number (optional) 'ABC1234'

Your date of birth*

 

Address*

 

Address 2

 

Suburb*

 

City*

 

Postcode*

 

Mobile number*

Alternative number

 

If you were not born in New Zealand – copies of your passport will have to be provided showing residency status

 

Country of Birth*

Occupation (optional)

 

Email*

 

Mother Ethnicity*

Baby Ethnicity*

 

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 NZ Residents
Birthcare Options for non NZ Residents
NOTE: Birthcare only provides facilities for normal labour and Birth.
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*

 

Lead Maternity Carer First Name*

Lead Maternity Carer Surname*

 

Name of Postnatal Midwife

 

Expected due date*

Proposed Place of Birth*

 

Gravida (number of pregnancies you have

had including this pregnancy)*

 

Parity (number of babies previously born)*

 

 

NEXT OF KIN OR CONTACT PERSON

 

First Name*

Surname*

 

Relationship to you

 

Their phone number*

Their evening contact number

 

Their address

 

Please ask your LMC if you need help completing the information below.

 

BLOOD INFORMATION

 

Blood Group*

Rhesus*

Hepatitis B*

 

MEDICAL HISTORY

 

Do you have any Medical history?*

 

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 / TERMS & CONDITIONS

 

View our information tour of Birthcare.

 

For Auckland residents, book your antenatal class, breastfeeding class, refresher class or Grandparents class with us.
Please refer to the 'Classes' menu option on www.birthcare.co.nz for further details.