MIDWIFERY CLIENT REGISTRATION



MIDWIFERY CLIENT REGISTRATION

|Name: First Middle Last |Date |Phone (home) |

|Maiden? | |(work) |

|Race/Ethnicity |Yrs Educ |Married? |Occupation And Type of Industry |Date of Birth |State of Birth |

|Address: Street City Zip |Inside City Limits? |How long at this |

|County |_____Yes _____No |address? |

|Father of Baby Name: First Middle Last |Race |Yrs Educ |Date of Birth |State of Birth |

|Address (if different from above) |Phone (home) |Occupation and Type of Industry |

| |(work) | |

|Partner/Husband (if different from the Father of Baby) |Emergency Contact Name: |

| |Phone: Relationship: |

|Method of Payment: ______Medicaid |Insurance Information: Co-pay_______ Name of Policy Holder:___________ |

|_____Cash _____Insurance ____Other |Policy#: Group #: |

|Mother’s Social Security Number (SSN) |Father’s SSN |SSN Requested for baby |Referred by: |

| | |___Yes ___No | |

FAMILY HISTORY—Indicate if anyone in your immediate family has ever had any of these, who; when.

❑ High blood pressure_________

❑ Cancer___________________

❑ Diabetes__________________

❑ Twins____________________

❑ Severe emotional problems___

❑ Alcohol/drug abuse_________

❑ Other____________________

FATHER OF BABY—INDICATE IF THE BABY’S FATHER HAS EVER HAD ANY OF THESE; WHEN.

❑ Sexually transmitted diseases_

❑ Herpes: GENITAL or ORAL (circle one)________________

❑ Severe emotional problems___

❑ Alcohol/drug abuse_________

❑ Tobacco use______________

❑ Other____________________

YOUR MOTHER’S HISTORY—Answer the following regarding your mother.

❑ # of pregnancies__________

❑ # of births_______________

❑ Miscarriages_____________

❑ Any complications_________

❑ Your weight at birth________

❑ Did she take DES with you? YES or NO (circle one)

PREVIOUS PREGNANCY OUTCOMES Please complete this table regarding your own pregnancies (from earliest to most recent)

|Date |# Weeks |Birth/Miscarriage/Termination |Comment/Problems |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Yes No Have you or the father of the baby (FOB) ever had a baby with a birth defect or mental retardation?

Yes No Do you or the FOB have any family members with birth defects or conditions diagnosed as genetic

or inherited?

Yes No Are you and the FOB related by blood? (i.e. cousins)

Yes No Are you or the FOB from any of these ethnic/racial groups? (circle)

JEWISH BLACK/AFRICAN ASIAN MEDITERRANEAN

Yes No Have you or the FOB ever had hepatitis or jaundice?

Yes No Have you ever used any drug intravenously (IV) or had a blood transfusion?

Yes No Have you ever had a sexual partner who used any drug IV, had a blood transfusion, or had bisexual relations?

Yes No Do you think you are at increased risk for having a baby with a birth defect or genetic problem?

Yes No Do you think you are at increased risk for AIDS/HIV?

Yes No Have you ever experienced dramatic fluctuations in your weight?

Yes No Have you ever had anorexia, bulimia, or other eating problems?

Yes No Is there anything about the development of your sexuality that you’d like to discuss?

Yes No Have you ever been in an abusive relationship, including now, or been abused (physically or emotionally

intimidated, beaten, injured, or made to take part in sexual activities against your will).

Yes No Have you ever had severe emotional problems?

Yes No Have you ever been on any medication for psychological problems?

Yes No Has anyone ever told you, or do you think, you have ever used alcohol or drugs excessively?

NAME: DATE OF BIRTH:

MEDICAL HISTORY: Please indicate if you have ever had any of these and when:

❑ Severe headaches__

❑ Eye/vision problems_

❑ Ear/hearing problems

❑ Dental problems____

❑ Thyroid problems___

❑ Rheumatic fever____

❑ Blood clotting prob.__

❑ Anemia___________

❑ Hemorrhage_______

❑ High blood pressure_

❑ Varicose veins_____

❑ Hemorrhoids_______

❑ Tuberculosis_______

❑ Asthma___________

❑ Skin disorders______

❑ Stomach problems__

❑ Ulcers____________

❑ Chicken pox_______

❑ Bowel problems____

❑ Blood in stool______

❑ Gall bladder prob.___

❑ Liver problems_____

❑ Hepatitis__________

❑ Diabetes__________

❑ Hypoglycemia______

❑ Bladder infection____

❑ Kidney infection____

❑ Urinary surgery_____

❑ Urethral dilation____

❑ Aching joints_______

❑ Pelvic/back injuries__

❑ Seizures__________

❑ Cancer___________

❑ Hospitalizations____

❑ Surgeries_________

❑ Other_____________

ALLERGIES:

Do you have any allergies? ___Yes ___No

Please list:

GYNECOLOGIC HISTORY

Age at first period________ Cycle length (days)_________

Regular? ___Yes ___No; Duration (days) _________

When was your last Pap? _______

Ever abnormal Pap? ___Yes ___No; Dates: ___________

Please indicate if you have ever had any of the following gynecological conditions and when:

❑ Yeast____________

❑ Trichomonas______

❑ Group B Strept_____

❑ Bacterial Vaginosis__

❑ Chlamydia_________

❑ Gonorrhea________

❑ Syphilis___________

❑ PID/Pelvic infection__

❑ Genital sores______

❑ Herpes:___________

___Genital ___Oral

❑ Genital warts_______

❑ Cervicitis__________

❑ Cervical surgery____

❑ Cervical polyp______

❑ Ovarian cyst_______

❑ Fibroids___________

❑ Endometriosis______

❑ Abnormal bleeding__

❑ Uterine surgery_____

❑ Breast lump(s)_____

❑ Breast surgery_____

❑ Infertility__________

❑ Other_____________

PRESENT PREGNANCY

Last menstrual period (1st day)_______

Was it a normal period? ___Yes ___No

Suspected date of conception: ______________

Positive pregnancy test date: _______________

Planned pregnancy? ___Yes ___No

Feelings about pregnancy _________________

Father’s/Partner’s feelings ________________

Most recent birth control used _____________

Contraception used in past: what, when, any problems?

_____________________________________

Please indicate if you’ve had any of the following problems during this pregnancy:

❑ Nausea

❑ Vomiting

❑ Fever

❑ Infections

❑ Headache

❑ Dizziness

❑ Indigestion

❑ Leg cramps

❑ Rash

❑ Backache

❑ Swelling

❑ Constipation

❑ Diarrhea

❑ Urinary complaints

❑ Gut or pelvic pain

❑ Vaginal bleeding

❑ Vaginal discharge

❑ Bleeding gums

❑ Varicose veins

❑ Hemorrhoids

❑ Depression

❑ Loneliness

❑ Family/relationship problems

❑ Work problems

❑ Other

Please indicate if you have used, experienced, or been exposed to any of the following during this pregnancy:

❑ Tobacco

❑ Alcohol

❑ Caffeine

❑ Marijuana

❑ Cocaine

❑ Street drugs

❑ Other meds

❑ Non-pres. Drugs

❑ Vitamins

❑ Herbs

❑ Fumes/sprays

❑ X-rays

❑ Ultrasound

❑ Measles/viruses

❑ Travel

❑ Vaccinations

❑ Cats

❑ Other

Planned place of birth :

____Home ____Birth Center ____Hospital

If home, please indicate if you have:

____Water ____Electricity ____Telephone

Are there any particular ethnic, cultural, or religious preferences for your care during pregnancy and birth that you would like to discuss?

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Midwifery Informed Consent

While the course of childbearing is a normal human function, it has been explained and I understand that although the likelihood is small in “low risk” women, in any particular case medical complications can arise unpredictably and suddenly. In such cases, mother and/or baby may be at greater risk being outside a hospital setting. I understand that there are also risks associated with labor and birth in a hospital setting. I have made an informed choice regarding the place of birth of my child. I understand that Christina Gutierrez, naturopathic midwife (ND, LM) and Sarah Ambrose, midwife (LM) carry certain emergency equipment but cannot duplicate all services available in the hospital setting. I understand that Christina Gutierrez, ND, LM and Sarah Ambrose LM do not employ electronic fetal monitoring, perform Cesarean sections, or administer blood transfusions.

I understand that the practice of medicine, nursing, and midwifery are not exact sciences, and I acknowledge that no guarantees can be made to me concerning results of treatments, exams, and procedures to be performed. I have the assurance that all information regarding my care while a client of Christina Gutierrez ND, LM and Sarah Ambrose LM will be shared with me. In addition, decisions regarding my care will be made in consultation with me. I am aware that Christina Gutierrez, ND, LM and Sarah Ambrose LM carry malpractice insurance.

I further understand that a naturopathic midwife functions under two licenses. The naturopathic license allows her to diagnose and treat disease, whereas the midwifery license allows for the care of normal pregnancy and birth.

In view of above, I understand that in the selection and treatment of women, Christina Gutierrez ND, LM and Sarah Ambrose LM will rely on my medical history and information about myself which I provide. I affirm that such information is and will be complete, correct, and accurate to the best of my knowledge. In addition, I understand that development of any of the following conditions during my pregnancy could be potentially dangerous for me and/or my baby. I agree to inform Christina Gutierrez, ND, LM and Sarah Ambrose LM if I detect any of the following during pregnancy:

Vaginal bleeding

Severe or continued nausea and vomiting

Continued severe headaches

Unusual or sudden swelling or puffiness

Blurred vision or spots before the eyes

Pain or burning on urination

Chills and/or fever

Sharp or continuous abdominal pain

Sudden gush of water or leaking of fluid from the vagina

Sudden or unusual decrease in the movement of the baby

I have had an opportunity to inform myself or be informed regarding the complications that could arise. My midwife informed me during the consultation visits of a list of potential medical complications that require referral. I agree to assume the risks associated with childbirth out-of-hospital. I am responsible for making informed choices, and asking questions to clarify issues about my own, and my baby’s health. I am also expected to follow-through with recommendations, treatments, and office visits as indicated.

I authorize Christina Gutierrez ND, LM and Sarah Ambrose LM to treat me and my baby and when necessary in an emergency, to take appropriate measures or transfer me, or my baby, to a medical physician or hospital for care.

Signature of client Date

__________

Signature of spouse or partner (optional) Date

[pic]Financial Policy

Thank you for choosing the physicians at Ground Floor Health to be your healthcare providers. We will do our best to provide you with the highest quality medical services. We feel that it is very important that our patients have a clear understanding of our expectations regarding billing and payment. Please read and sign the following financial policy prior to your treatment. Should you have any questions, feel free to ask.

Insurance Billing:

Ground Floor Health is contracted with most major insurance companies. You are welcome to ask for a list or if we are contracted with your specific company. For patients with these insurance plans, we bill insurance directly and accept payment plus any co-payments, co-insurance, deductibles and payments for non-covered services as payment in full. Although we are contracted with your insurance company, it does not guarantee that your plan covers all visits. Patients are responsible to know the terms of their insurance and whether naturopathic, midwifery, and acupuncture services are covered.

Office Fees:

• Fees are determined after the visit has taken place and depend on the complexity of the health concern, which procedures were performed, and the amount of time spent with the patient.

• If we are not contracted with your insurance company or you do not have medical insurance, we offer an income-based time of service discount. If you are having financial difficulty, we will be happy to work with you. You may want to establish a payment plan. We ask that these payments be made on time monthly and be paid in full within six months.

• Annual Exams and Dual Licensed Providers: If medical treatment is requested during an annual physical exam, I understand that my provider is allowed to bill the insurance carrier for those services separately from the annual exam charge. I also understand that if my provider is credentialed as both an acupuncturist and a naturopath and both modalities are used during the visit, my provider will bill both visits separately.

Payment Policy

• Full payment for visit co-pays, supplements and lab fees must be rendered at time of service and can be made by cash, check, Visa or MasterCard.

• Patients will be held responsible for non-payment by their insurance company. Accounts unpaid by the insurance company greater than 90 days will be billed to the patient.

• A late fee will be assessed beginning with the second billing statement if there is failure to make payment or make contact with us in 30 days. If there is no response to these actions, further action may be taken.

• If you pay for services by check and that check is returned for non-sufficient funds, we will charge an additional $40 to your account. If that happens, you will be asked to remit the amount of the check plus the service charge in cash within 10 days. If your account has not cleared by then, we may take further action.

• Showing up for your scheduled appointment is very important. If you are unable to make your appointment, please give our office 24 hours notice so that we may give another patient that time. Patients that “no show” or do not cancel 24 hours prior to their appointment may be assessed an appointment charge of $25. This charge is your responsibility. Insurance companies do not pay for missed appointments.

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I, ______________________________________________agree to the above-defined financial policies of Ground Floor Health. I give permission for the release of information requested by my insurance company to assist in processing my insurance claims. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that I’m fully responsible for the total payment of all services and procedures performed in this office. This includes any service that may not be covered by my medical insurance. In the case of default of payment, I am responsible for full payment of the balance, interest accrued, and any collection costs or legal fees incurred to collect on this account.

I, the undersigned, have read, understand, and agree to the information and conditions specified in this document.

_______________________________________________________________________ _________________________________

Patient/Guardian Name and Signature Date

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