Informed Consent Form for Hospital Transfer. Please carefully read this form, sign it and return it to us.

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1 Dear Expectant Parent: Welcome! We look forward to your stay at the Puget Sound Birth Center in Kirkland. Enclosed is some information that will assist you in pre-registering and will prepare you for your visit. Please return the completed paperwork to your midwife so she may send it in to us and complete your registration process. Please note that these forms must be returned prior to your admission to the birth center. Registration Form & Insurance Card. This form is used to provide us with your address, phone, & insurance information. Please attach a photocopy or photograph of the front and back of your insurance card. Informed Consent Form for Hospital Transfer. Please carefully read this form, sign it and return it to us. Notice of Privacy Practices & Acknowledgement Form. This notice describes how medical information about you may be used & disclosed & how you can get access to this information. Please read and retain this document, then sign the acknowledgement form and return it to us. Admission to the Birth Center. Unlike a typical hospital, the birth center is not staffed 24 hours a day. Medical staff is provided by your midwife when you are in labor. Therefore, when you go into labor, be sure to call your midwife to arrange admission to the birth center. She will meet you at the birth center once you have reached active labor. If you show up without your midwife, medical care will not be available. For touring the birth center: We are available at certain times during the week to show you the birth suites: Monday Thursday, anytime between 1-2pm Friday, anytime between 10:30 2pm. Appointments are optional, but please do call us before you leave on the day you would like to come in. We don t want you to make the trip over if we have several births going on and are therefore unable to show you the rooms. Additionally, some Fridays we have meetings and therefore will be unavailable to show you around. If you would like to come on a Friday, please call to check in with us at some point the week before to make sure we will be available! Congratulations on the upcoming addition to your family!

2 Midwife s Name: Estimated Due Date: Planned Place of Birth: PSBC Kirkland PSBC Renton Client s Name: First Middle Last Maiden Client s Birth Date: Age: Social Security #: Street Address: Mailing Address (if different from above): City: State: Zip: Phone: (cell) (home): (work): Occupation: Address: Employer: Primary Care Physician: Phone #: Partner/Spouse: First Middle Last Occupation: Employer: Birth Date: Age: Social Security #: Address (if different from yours): Phone: (cell) (home): (work): Name: Address: Emergency Numbers/Message Phones Relationship: Phone: (cell) (home): (work): May we use this number as a message phone if we are unable to reach you? Insurance Information Insurance Co. Name: Insured Name: ID #: Group #: Phone Number of Ins. Co. (should be on the card): Insured Employer: Work Phone#: Are you covered by Secondary Insurance? (Please Circle) Yes / No Insurance Co. Name: Insured Name: ID #: Group #: Phone Number of Ins. Co. (should be on the card): Acknowledgement and Insurance Payment Authorization I certify that the information in this form is correct to the best of my knowledge. I hereby authorize the Puget Sound Midwives & Birth Center or any of its representatives be paid directly by my insurance company. I also authorize Puget Sound Midwives & Birth Center or any of its representatives to release any information necessary to process my insurance claim. Signature of Client: Date: Revision Date: 10/15/14 lc

3 Birth Center Informed Consent & Plan for Hospital Transport Midwives with admitting privileges at the Puget Sound Birth Center (PSBC) are expected to adhere to the Midwives Association of Washington State (MAWS) Standards for the Practice of Midwifery ( in identifying significant deviations from normal and to consult with or transfer care to a hospital accordingly. Your midwife is also expected to maintain an active license to practice in Washington State, to be a member of MAWS, and carry appropriate malpractice insurance. If, during your stay at PSBC, your midwife determines the need for consultation or transport to a hospital, options are dependent on the clinical circumstances and are generally as follows: Problem Mode of Transport Hospital Evergreen Hospital (Kirkland) Valley Medical Center (Renton) Non-emergent labor (antepartum) or postpartum transfer Private automobile University of Washington Swedish First Hill (Seattle) Overlake (Bellevue) Non-emergent neonatal transfer of a stable infant Private automobile Evergreen Hospital (Kirkland) Valley Medical Center (Renton) Children s Hospital (Seattle) Emergency transfer- time is of the essence, additional medical procedures needed en route or additional emergency assistance required Medic Unit (911) Evergreen Hospital (Kirkland) Valley Medical Center (Renton) I/We have chosen to birth our baby at the Puget Sound Birth Center attended by a midwife with admitting privileges. I/We understand that admission to PSBC in labor is contingent upon the normal progress of this pregnancy, compliance with routine prenatal care and upholding the client responsibilities as outlined and discussed with me by my midwife. I/We understand that narcotic and epidural pain medications, vacuum extractor, forceps and Cesarean Section are not available at PSBC and need for any of the above are indications for transport to hospital.

4 I/We understand that there are medications available at PSBC for the control of shock, seizure, and post-partum hemorrhage and newborn resuscitation equipment is on site. Emergency medications may be used in addition to transport to hospital. I/We understand that birth is not without risk and that there is no guarantee of the outcome of birth in any setting, in or out of the hospital. I/We understand the potential risks, benefits, and responsibilities involved in choosing an out-of-hospital birth at PSBC and am/are willing to accept these. I/We understand that PSBC cannot be held responsible for the clinical care provided by my midwife. Client s signature Date Partner s signature Date

5 Declaration of Low-Risk Maternal Client According to the WAC (18) (a) (e) Midwife s Name: Date: Client s Name: EDD: According to the WA (13) (a) (e): 18) "Low-risk maternal client" means an individual who: (a) Is at term gestation, in general good health with uncomplicated prenatal course and participating in ongoing prenatal care, and prospects for a normal uncomplicated birth as defined by reasonable and generally accepted criteria of maternal and fetal health; (b) Has no previous major uterine wall surgery, cesarean section, or obstetrical complications likely to recur; (c) Has no significant signs or symptoms of anemia, active herpes genitalia, placenta praevia, known noncephalic presentation during active labor, pregnancy-induced hypertension, persistent polyhydramnios or persistent oligohydramnios, abruptio placenta, chorioamnionitis, known multiple gestation, intrauterine growth restriction, or substance abuse; (d) Is in progressive labor; and (e) Is appropriate for a setting where methods of anesthesia are limited. I certify all the above to be true by checking each item s box and providing my signature prior to my client s delivery. Signature:. I certify that my client,, qualifies as low risk as defined above. I,, declare that at the current time I have a consultation relationship with a physician qualified by training and experience in obstetrics and gynecology with admitting privileges to a community hospital is available by phone twenty four hours a day. 10/15/2014

6 Acknowledgment of Receipt I have had the opportunity to review PSMBC's: HIPAA Notice of Privacy Practices which describes how my health information is used and shared. I understand that PSMBC has the right to change this Notice at any time. Client Bill of Rights, which lists my rights as a client. I may obtain a personal copy of either document by request or by visiting Your signature Date Print your name

7 Supply list for Birth Center stay 3 weeks prior to your due date, have the following items assembled and in one place. Car seat for baby Clothes you would like to labor in, you may need more than one set Swimsuit (if desired) and extra clothes for support people/partners in the tub Clothes to wear home after the birth Toiletries for shower (towels are provided) Clothes for baby Diapers (disposables provided) Receiving blankets to take baby home Camera or video recorder, if desired Food for yourself and your birth team. Several bottles of your favorite flavors of Recharge, Coconut Water, Juice, etc. Popsicles, yogurt, fruit or crackers are just a few examples of things you may want in labor. We have a refrigerator, freezer, sink and microwave are available for your use. Also, bring a hearty meal for after the birth (you ll be hungry)! Any music you may want to listen to. You can play Ipod, MP3 or CD. We have a sound system in all of the birth rooms. Phone calls: The birth center is not staffed 24 hours a day. Therefore, during the off hours, our main phone line is forwarded to our answering service. You should direct your friends/family to call your cell phone. We look forward to seeing you and your family!

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