Patient Information Please provide the following: Registration for OB/GYN and Hospital Care Please print and press firmly with a ball-point pen Name: Last First MI Prefer to be called Address: Age: Birth Date: / / Month day year Apartment or P.O. Box Number Marital Status:_ S M D W Sep (circle one) City: State: Zip: Home Phone: ( ) Employer: (Name) (City) (Occupation) Who referred you to our office: OB/GYN Physician: Have you had services at Evergreen Hospital before? Yes No Work Phone: ( ) Soc Sec: Family or Primary Care Physician: Were you seen under a different name? If yes, former name: (including lab, x-ray or ER) (circle one) Family Information Husband/Partner or Parent Name Relationship to Patient: Birth Date: / / Soc Sec Employer: Wk Phone: ( ) (Name) (City) (Occupation) Hm Phone: ( ) If patient is a minor, with whom does child live? Financial and Insurance Information Primary Insurance: Group #: Subscr. #: Policyholder Name: Ins. Co. Phone # ( ) Newborn Information (if applicable) Baby s Last Name: Due Date: Baby s Insurance: Please present Insurance Card(s) to Receptionist Secondary Insurance: Group #: Subscr. #: Policyholder Name: Ins. Co. Phone # ( ) Name of Baby s Doctor: Primary Secondary Other Persons to Call In Case of Emergency Next of Kin: (or legal guardian, if same as family information, note same) Relationship to Patient: Emergency Contact: (other than a relative or person living with you) Relationship to Patient: Home Phone: ( ) Work Phone: ( ) Home Phone: ( ) Work Phone: ( ) The hospital requests the following information to include as a part of your medical record: Advance Directives: Do you have a living will? Yes No Do you have a Healthcare Power-of-Attorney? Yes No Religion: If you would like it included in your record, what is your religious preference? Release of Benefits & Information: I authorize my insurance benefits be paid directly to the doctor. I am financially responsible for any balance due. I authorize the doctor or insurance company to release any information required for processing insurance claims. I understand this may include information regarding HIV, sexually transmitted diseases, mental health, drug and/or alcohol use. SIGNED: DATE: OFFICE USE ONLY: Registration to Admitting at 12 weeks Date sent: Initials: Pre-Natal to Admitting at 36 weeks Date sent: Initials: White - physicians office Yellow - admitting office FORM ID ADM 153 OB/GYN, Item ID I1000120 (10/00)
Contact Information (Sticker) Name: Email address: I prefer to be contacted at: (For EvergreenHealth information updates only) (Please list in order of preference and label cell, home, spouse, friend, other, etc.) Phone Number Description 1. ( ) 2. ( ) 3. ( ) 4. ( ) OK to call and confirm appointments OK to call with NORMAL lab results OK to call with ALL lab results OK to leave message with results or appointments Information can be released to: Name Relationship Name Relationship Comments: Signature Date
Medication List Name: DOB: Date: It is very important for your Midwives to know all the medications you are taking. We will need the following detailed medication information in addition to what you supplied in your Patient Portal online history. Please complete this list with all medications, including prescribed medications, over the counter and herbal medications, vitamins and home remedies. Your Midwife will need this list at the time of your appointment. (Use back if additional space is needed.) Medication Dose Why Taken How Long Prescribed by Medication Allergies: Please identify your preferred Pharmacy with location and phone numbers below: Pharmacy Name: Street Address: City, State Phone #: Fax #: Mail order RX? Yes No 060614-MH
Midwifery Consent for Optional Pregnancy Screening Routine Tests During Pregnancy First prenatal visit: OB Panel blood test which includes a complete blood count, blood type, rubella status, Hepatitis B surface antigen, and antibody screen Urine culture to rule out a urinary tract infection Between 26 and 28 weeks of your pregnancy: 2 hour glucose tolerance test blood test to screen for gestational diabetes Complete blood count blood test to check for anemia At your 36 week Birth Plan visit: Group B Strep test to check for the presence of GBS via a vaginal and rectal swab Optional Tests During Pregnancy Sexually Transmitted Infection Screening HIV: HIV is a virus that weakens the body s defense against disease and causes AIDS. If a woman has HIV, she can pass it to her baby during pregnancy, during labor, or through breastfeeding. If an HIV infection is found before birth, medications can be given that greatly reduce the risk of the baby being infected. HIV screening is advised for all pregnant women. Gonorrhea/chlamydia: Gonorrhea and chlamydia are sexually transmitted infections that often have no symptoms. If a woman has either of these, she can pass them on to her baby during birth, which can lead to conjunctivitis in the newborn and if left untreated, blindness. These infections can be detected through urine testing as well as a cervical swab. Gonorrhea and chlamydia screening is advised for all pregnant women.
Midwifery Consent for Optional Pregnancy Screening Optional Genetic Screening Tests Carrier screening via a blood test: Screening can test if you are a carrier for certain genetic conditions including cystic fibrosis, spinal muscular atrophy, and fragile-x Syndrome. There is also the option of carrier screening for over 100 other genetic disorders. If you are interested, we recommend a referral to a genetic counselor at Maternal Fetal Medicine to discuss further. Non-invasive Prenatal Testing (also known as cell-free DNA testing): This is a blood test that is 99% accurate to screen for the risk of Down syndrome and can also screen for Trisomy 18, Trisomy 13 and sex chromosome abnormalities. This includes a referral to a genetic counselor and is done at Maternal Fetal Medicine. It can accompany the Nuchal Translucency ultrasound (see below). Combined Screen (also known as the Nuchal Translucency Scan and blood test): This test screens for the risk of having a child with Down syndrome, Trisomy 18 and Trisomy 13. It is done at Maternal Fetal Medicine and involves an ultrasound done at approximately 11-13 weeks 6 days to measure the thickness of the area behind the baby s neck (nuchal translucency) and is combined with blood work. This will detect approximately 90% of children with Down syndrome. Quad Screen: A blood test performed between 15 and 21 weeks of your pregnancy to calculate the risk of having a baby with Down syndrome, neural tube defects (spina bifida or other associated anomalies) and Trisomy 18. It detects approximately 70% of babies with Down syndrome. Patient Signature: Date: Time: Updated 8/2015