Community Midwifery Program

TOPAS / ABM / EDB:
MBL / Parity:
Pack / Email:

Community Midwifery Program

Application Form

OFFICE USE ONLY

Client ID / Date received / Date entered / Previous Client UR / Date Allocated/
Declined / Manager Accepted by / Midwife / Date Midwife Informed / Client URMN / Client
Email sent

All information MUST be completed for your application to be assessed

CLIENT DETAILS

Mother’s full given name:
Father/partner’s name:
Mother’s maiden name:
Residential address:
Suburb: / Postcode:
Postal address:
(if different from above) / Postcode:
Telephone numbers:
Home: / Work: / Mobile:
Email address:
Mother’s date of birth: / Age:
Country of origin/ethnicity: / □Caucasian □Aboriginal/Torres Strait Islander□ Asian□Afro Caribbean□Polynesian □Maori □Other
Do you require the services of an interpreter?Yes No
Pre Pregnancy Weight ______kg Height ______cm
YOUR DOCTOR (Please give full details)(Either your specialist doctor or your family GP)
Name: / Phone:
Address:
Postcode:
Private Health Provider: ______
Membership No.: ______ / Medicare No.: ______
Do you have private ambulance cover? Yes No
If No, please discuss with your midwife
Do you have any special needs?Yes No (i.e. limited mobility, hearing deficit)
Do you have a carer? Yes No
Name of carer: ______
Do you suffer from any serious illnesses or medical conditions? Yes No
If yes, please indicate nature of illness/condition

THIS PREGNANCY

Expected date of birth / How many babies have you birthed?
(e.g. 1, 2, 5,…)
Please select ONE option only
Preferred place of birth: (support hospital will be the nearest supporting hospital)
Home Kalamunda Family Birth Centre (Spaces limited to 4 per Month)
OR
I would like a hospital domino birth at:(you must reside within the catchment area to be eligible for a Domino birth at KEMH)
KEMH Armadale Fiona Stanley Rockingham Swan District Joondalup
Please note that CMP is currently not allocating placesto VBAC women. We do however encourage women wishing for a VBAC to submit an application so that CMP can evidence demand for this service in the future.
Did you have any problems with previous pregnancies or births?Yes No
If yes, please give details or contact the Midwifery Manager ati.e.Caesarean section, heavy bleeding after birth, raisedblood pressure, diabetes
"I confirm that I will comply with the CMP minimum standards of screening tests in pregnancy to include an ultrasound scan and a blood test to check my iron levels and blood group."
Yes No
In an emergencywould you accept a blood transfusion? Yes No
Are you currently taking any medication? Yes No
If yes please give details.
______
Do you have a preference for a particular midwife, if she is available?Yes No
Which midwife?
Have you used the Community Midwifery Program for previous pregnancies?Yes No
Additional comments
(Please feel free to tell us anything you think is relevant to your application)
How did you find out about our Community Midwifery Program?
□Friends & Family □Previous Client □Birthing Centre / KEMH □GP/OBS □Phone Book □Internet
□Newspaper Article □Newspaper Advert □Bounty Bag □Shopping Centre □Pamphlet / Card
□Expo/Community Event □Other – (please specify)

Thank you for your application for a place on the Community Midwifery Program.

Please note that applications are assessed on a first-in-first-served basis.

By submitting this application you give your consent to Community Midwifery Program sharing your medical records with other Health Professionals involved with your careand in case of emergency, I authorise any member of the CMP to take all appropriate measures to support my antenatal, birth and postnatal care.All information will be treated as strictly confidential.

Please fax, email or post your completed Application Form to CMP Administration:

Mail: Internal Box 86, Lakeside Shopping Centre, 420 Joondalup Drive, JoondalupWA 6027

Tel: 9301 9227 Fax: 9301 9218

Email:

Version 14 – 18/02/15

Community Midwifery ProgramApplication FormPage 1of 2