Healthcare OB Paperwork Form

Healthcare OB Paperwork Form

Patient Information

Patient Name:    Date of Birth:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy / ID Number:    Group Number:

Obstetric History and Current Pregnancy

Gravida (total pregnancies):    Para (term births):    Abortions / Miscarriages:

Date of Last Menstrual Period (LMP):    Estimated Due Date (if known):

Medical History

Please indicate if you have been diagnosed with any of the following conditions (check all that apply):

Diabetes    Hypertension    Thyroid disorder

Asthma    Cardiac disease    Autoimmune disorder

None of the above

Social and Family History

Occupation:    Employer:

Tobacco use:    Alcohol use:    Recreational drugs:

Testing and Screening Consents

Please indicate consent or decline for common prenatal screenings and procedures. Consent implies the provider may perform the test as clinically indicated and order related laboratory work.

Consent to routine prenatal laboratory testing (bloodwork, urine)

Consent to HIV screening (unless specifically declined)    Decline HIV screening

Consent to Group B Streptococcus (GBS) testing    Consent to glucose screening for gestational diabetes

Authorization to Release Medical Information

I authorize the release of my obstetric medical information for continuity of care, referrals, insurance processing, or transfer of care to other treating providers. This authorization includes prenatal records, laboratory and imaging results, and birth records unless otherwise specified. I understand that my HIV-related information may be released if applicable and permitted by law.

Purpose of Release:    Authorization Expiration Date:

I understand I may revoke this authorization in writing at any time except to the extent information has already been released in reliance on this authorization. This authorization is voluntary and will not affect my ability to obtain treatment unless treatment is conditioned on signing.

Privacy Acknowledgment & Consent for Treatment

I acknowledge that I have been offered access to the provider's Notice of Privacy Practices and that I understand my rights regarding protected health information. By signing below I consent to routine obstetric care and diagnostic procedures deemed necessary by my treating clinician, including but not limited to examinations, laboratory testing, imaging, and administration of medications associated with prenatal care and delivery.

I understand that obstetric care and delivery involve inherent risks. I have the right to discuss risks, benefits, and alternatives with my clinician and to withdraw consent at any time by notifying the provider in writing, except in emergencies where withdrawal may not be possible.

Patient Preferences / Birth Plan Summary

Acknowledgment and Certification

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that it is my responsibility to notify the treating facility of any changes to my medical condition, medications, allergies, or insurance coverage. I authorize the release of information as described above and consent to the provision of care as indicated.

Sign Now